Atlas of Hair Pathology PDF

An Atlas of HAIR PATHOLOGY WITH
CLINICAL CORRELATIONS
THE ENCYCLOPEDIA OF VISUAL MEDICINE SERIES
An Atlas of HAIR
PATHOLOGY WITH
CLINICAL
CORRELATIONS
LEONARD C.SPERLING, MD, COL, MC, USA
Professor of Dermatology and Pathology
Chair, Department of Dermatology
Uniformed Services University
Bethesda, MD, USA
The Parthenon Publishing Group

International Publishers in Medicine, Science &
Technology
A CRC PRESS COMPANY
BOCA RATON LONDON NEW YORK
WASHINGTON, D.C
Published in the USA by

345 Park Avenue South, 10th Floor
New York, NY 10010, USA
This edition published in the Taylor & Francis e-Library, 2005.
To purchase your own copy of this or any of Taylor & Francis or Routledges collection of
thousands of eBooks please go to www.eBookstore.tandf.co.uk.
Published in the UK and Europe by
2325 Blades Court
Deodar Road
London SW 15 2NU, UK
Copyright 2003, The Parthenon Publishing Group
Library of Congress Cataloging-in-Publication Data
Sperling, Leonard C.
An atlas of hair pathology with clinical correlations / Leonard C.Sperling
p. ; cm. -- (The encyclopedia of visual medicine series)
Includes bibliographical references and index.
ISBN 1-84214-203-8 (alk. paper)
1. HairDiseasesAtlases. 2. Hair manifestations of general diseasesAdases. I. Tide. II. Series.
[DNLM: 1. Hair Diseases-pathologyAdases. 2. Hair Diseases-therapy-Adases. WR
17 S749a 2003]
RL151.S648 2003
616.546dc21
2003043327
British Library Cataloguing in Publication Data
Sperling, Leonard C.
An atlas of hair pathology : with clinical correlations.(The encyclopedia of visual medicine series)
1. HairDiseases 2. HairDiseasesDiagnosis
I. Title
616.54607
ISBN 0-203-49066-5 Master e-book ISBN
ISBN 0-203-59641-2 (Adobe eReader Format)

ISBN 1842142038 (Print Edition)
No part of this book may be reproduced in any form without permission from the publishers
except for the quotation of brief passages for the purposes of review
Contents
Preface
vi
Acknowledgements
vii
1.
Normal hair anatomy and architecture
2.
Specimen acquisition, handling and processing
32
3.
Evaluating and describing transverse (horizontal) sections
37
4.
Classification of hair disease
46
5.
Distinctive or critical histological features and associated diseases
50
6.
Clinical correlation
61
7.
Senescent balding (senile alopecia)
65
8.
Androgenetic alopecia
68
9.
Telogen effluvium
81
10.
Trichotillomania
87
11.
Traction alopecia
94
12.
Postoperative (pressure-induced) alopecia
101
13.
Temporal triangular alopecia
105
14.
Alopecia areata
109
15.
Syphilitic alopecia
139
16.
Non-scarring alopecia from systemic lupus erythematosus
147
17.
Loose anagen hair syndrome
155
18.
Central, centrifugal scarring alopecia
163
19.
Lichen planopilaris
181
20.
Frontal fibrosing alopecia
193
21.
Chronic cutaneous lupus erythematosus (discoid lupus

erythematosus)
194
22.
Brocqs alopecia (pseudopelade of Brocq) and burnt out

scarring alopecia
207
23.
Acne keloidalis (folliculitis keloidalis)
214
24.
Dissecting cellulitis of the scalp (perifolliculitis capitis abscedens

et suffodiens)
224
25.
Tufted folliculitis
232
26.
Tinea capitis
234
27.
Aplasia cutis congenita of the scalp
244
28.
Overview of hair shaft disorders
249
Index
267
Preface
This textbook is the first comprehensive presentation of the microscopic

pathology of hair disease. The subject is an area of great difficulty for
pathologists and dermatopathologists who must evaluate specimens submitted
with the clinical diagnosis of hair disease. The pathology of hair disease is rarely
or very superficially taught during residency training. Many pathologists are
inexpert at evaluating hair biopsy specimens, and often the submitting
dermatologist must attempt to act as pathologist as well as clinician.
The book is intended to serve as a primer, an atlas and a reference text. As a
primer, the book reviews basic information, including hair anatomy and the nuts
and bolts of processing and evaluating specimens. The author assumes that the
reader knows very little about hair disease or hair pathology, and so a step-bystep approach is utilized. As an atlas, the book is rich in photographs
demonstrating both basic and advanced histological features of hair disease. As a
reference, the book includes the most up-to-date information about the pathology
of hair disease presented in a synopsis format. Basic clinical features are also
reviewed to provide clinicalpathological correlation.
I expect that dermatopathologists will be the most enthusiastic audience for
the book. However, general pathologists and dermatologists who care for
patients with hair loss will also find the book to be useful.
The data source for the book is largely my collection of histological
specimens and clinical photographs, although several dermatopathologists were
kind enough to lend me some useful slides. The majority of my specimens were
obtained from my own patients, many of whom I have known for years. This
allows for very good clinical-pathological correlation. A few figures are based on
material borrowed from other specialists in the field.
Leonard C.Sperling, MD, COL, MC, USA
Professor of Dermatology and Pathology
Chair, Department of Dermatology
Uniformed Services University
Bethesda, Maryland, USA
Acknowledgements
My interest in the pathology of hair disease was stimulated by Dr John

T.Headingtons seminal article on the subject (Headington J.Transverse
microscopic anatomy of the human scalp. Arch Dermatol 1984; 120:44956). Dr
Headington was neither the first to utilize transverse sectioning nor the first to
describe the histological features of hair disease. However, his teachings on the
subject have had such a profound influence on enthusiasts of hair disease that Dr
Headington can be regarded as the father of hair disease pathology.
I have been fortunate to follow in the footsteps of many pioneers in the field.
Many of the concepts and observations described in the text are not my own, but
have been passed down to us by such giants as David Whiting, Vera Price,
Wilma Bergfeld, Al Solomon, Elise Olsen, Rodney Sinclair and Rodney
Dawber. David Whiting, in particular, has been a mentor and cheerleader for
much of my work. I have also received support and encouragement from many
other leaders in the field of hair disease such as Jerry Shapiro, George Cotsarelis,
Kurt Stenn and Jeffrey Miller. The magnificent textbooks of A. Bernard
Ackerman have been an inspiration, and his love for teaching dermatopathology
is infectious.
I still have much to learn about the pathology of hair disease. If I were to
postpone publishing this work until I felt truly expert, it might never happen. The
confidence to move forward is due, in part, to the encouragement I have received
from my academic idols and mentors: William D.James, Stephen I.Katz, John
Stanley, Kim Yancey, Jeffrey Callen, Kenneth Arndt, George Lupton and Val
Hemming, among others.
And of course Joanne and Laura are always there for me. They make the effort
worthwhile.
CHAPTER 1
Normal hair anatomy and architecture
The histological findings in many forms of hair loss are subtle, and an accurate
diagnosis depends on distinguishing abnormal from normal follicular
architecture. The word architecture refers to the anatomy of individual hair
follicles as well as the number, size and distribution of follicles within a biopsy
specimen.
SIZE OF HAIRS: TERMINAL,
INDETERMINATE,VELLUS
Long, thick hairs with bulbs in the fat are called terminal hairs. Vellus hairs are
thin, short and often hypopigmented, with bulbs located in the upper portion of
the dermis. Indeterminate hairs are intermediate in size between terminal and
vellus hairs. Hair shaft diameters can be readily measured in transverse section;
terminal hairs are thicker than 0.06 mm and vellus hairs are less than 0.03 mm. A
vellus hair can be readily identified by simple inspection, since its inner root
sheath will be as thick as or thicker than the shaft (Figures 1.1 and 1.2).
PHASE OF HAIR CYCLE: ANAGEN,
CATAGEN,TELOGEN
Every follicle, regardless of size, can be found in one of three phases of the hair
cycle. The anagen phase is the active growing period, and lasts weeks to years,
depending on the size and site of the hair. For human terminal scalp hair, anagen
lasts between 2 and 7 years. Catagen is a brief transitional phase between anagen
and telogen, and lasts about 23 weeks. The telogen phase lasts about 100 days,
at the end of which the shaft is shed. Depending on the individual, between 85
and 100% of terminal scalp hair is in the anagen phase at any given time; 015%
is in the telogen phase and only about 1% is in the catagen phase. The percentage
of terminal telogen hairs present (usually based on a lock of hairs forcibly
plucked from the scalp) is called the telogen count. Average telogen counts
are in the range of 613%, and a count greater than 20% is abnormal.
2 AN ATLAS OF HAIR PATHOLOGY
Figure 1.1 Terminal versus vellus hairs. Two terminal hairs and a single vellus hair,
sectioned at the level of the mid-dermis. This specimen was obtained from a normal adult
scalp. Original magnification 200
Figure 1.2 Terminal versus vellus hairs. Two terminal hairs and a single vellus hair,
sectioned at the level of the infundibulum (upper dermis). A sweat duct (lower left corner)
is present for comparison. Original magnification 200
Anagen hair anatomy

Anagen, catagen and telogen hairs differ considerably in their appearance.
Anagen hairs can be described as having four zones. From deep to superficial,
these zones are the hair bulb, the suprabulbar zone, the isthmus and the
infundibulum.
The hair bulb, usually located in the fat, is composed of the hair matrix, the
basophilic germinative layer, which surrounds the hair papilla. The hair papilla
is a mesenchymal structure derived from the dermis. Inferiorly, the stalk of the
papilla merges with the fibrous root sheath, which surrounds the entire follicle
and blends into the overlying dermis (Figures 1.3 and 1.4).
Just above the hair bulb is the suprabulbar zone, at which point the various
layers of the anagen follicle begin to differentiate. Transverse sectioning allows
all the layers of the anagen follicle to be easily identified at this level. Starting
NORMAL HAIR ANATOMY AND ARCHITECTURE 3
Figure 1.3 Terminal anagen hair bulb, vertical section. The bulbs of terminal hairs are
usually located in the superficial fat or deep dermis. The basophilic (and often pigmented)
hair matrix surrounds the dermal papilla (P), whose stalk (S) is continuous inferiorly with
the fibrous root sheath. Original magnification 200
from the center of the follicle and moving outward, the layers are the hair shaft
medulla, the hair shaft cortex, the cuticular layer, Huxleys layer of the inner
root sheath, Henles layer of the inner root sheath, the glassy (vitreous) layer and
the fibrous root sheath. The cuticular layer is composed of the inter-locking
flattened cells of the hair shaft cuticle and the inner root sheath cuticle. These
cells are so tightly inter-locked that they appear to form a single anatomical layer
(Figures 1.5 and 1.6).
Moving toward the skin surface, the next zone is the isthmus. The inferior
landmark for the isthmus is the insertion of the arrector pili muscle into the
fibrous root sheath of the follicle. The superior landmark for the isthmus is the
entrance of the sebaceous duct into the follicular canal. The isthmus is an
important transitional zone of follicular keratinization. In the mid-portion of the
isthmus, the inner root sheath desquamates, resulting in a separation between the
hair shaft and the follicular wall. At this point, the cells of the outer root sheath
Figure 1.4 Terminal anagen hair bulb, transverse section. Original magnification 400
begin to cornify without the formation of a granular cell layer. This is called
trichilemmal keratinization (Figures 1.7 and 1.8).
The uppermost zone of the follicle is the infundibulum, bounded inferiorly by
the entry of the sebaceous duct. Cornification of the outer root sheath occurs with
the formation of a granular cell layer, similar to the epidermal surface (Figures
1.9, 1.10 and 1.11).
The epithelium adjacent to the insertion of the arrector pili muscle (the bulge)
is the putative site of the follicular stem cells. Although an actual anatomical
bulge is evident in rodent follicles, human follicles do not usually have an
obvious protuberance of epithelium at this site. Special histochemical stains
directed against antigens such as cytokeratin 15 are required to identify the stem
cells (Figures 1.12 and 1.13).
Hair shaft size and shape differs between racial groups. The hair shafts of
African Americans tend to be elliptical or kidney-bean-shaped (Figure 1.14), and
are situated eccentrically within the epithelium of the follicle. Caucasian hair
shafts tend to be circular or slightly oval, and are usually located directly in the
center of the follicle.
Catagen hair anatomy
Each terminal anagen hair on the scalp grows for about 27 years, depending on
the individual. At the end of that time, the hair shaft ceases active growth and
enters a brief catagen phase. Within just a week or two, the entire anatomy of the
follicle changes. At the beginning of catagen, the hair matrix disappears and is
replaced by a thin rim of epithelial cells surrounding the hair papilla. These
epithelial cells along with an overlying homogeneous column of epithelial cells
demonstrate nuclear pyknosis. The epithelium of the lower follicle is undergoing
disintegration by way of apoptosis (programmed cell death). As these epithelial
changes occur, the vitreous (or glassy) layer markedly thickens, so that it
becomes a prominent structure. The fibrous root sheath also thickens. As the
catagen phase progresses over a 23-week period, the hair papilla follows the
Figure 1.5 Terminal anagen hair, suprabulbar zone, vertical section. Just above the bulb,
the various layers of the anagen hair can be identified: medulla (M) if present, cortex (C),
cuticular layer (Cu), inner root sheath (IRS), outer root sheath (ORS), vitreous/glassy layer
(V) and fibrous root sheath (F). Original magnification 400
disintegrating epithelial column upwards into the dermis, and the papilla
eventually comes to rest just below the bulge zone (attachment of arrector pili
muscle).
As the epithelial column moves upward, a collapsed fibrous root sheath is left
behind. This collapsed structure is called the stela (or stele; plural, stelae),
derived from the Greek word for pillar. The stela is also referred to as the
follicular streamer. In this text, the terms stela and streamer are considered
to be synonymous.
Just above the epithelial column of the catagen hair, an expanded mass of
epithelium forms the presumptive club hair. Early in catagen the cells of the
presumptive club are still nucleated, but the nuclei disappear as the club begins
to cornify from the center outward (Figures 1.151.22).
Figure 1.6 Terminal anagen hair, suprabulbar zone, transverse section. Original
magnification 400
Telogen hair anatomy

At the end of catagen and the beginning of telogen, the hair papilla is a
condensed ball of spindle-shaped nuclei within a scanty stroma. The papilla lies
just below a nipple of epithelium called the secondary hair germ (Figure 1.23).
When sectioned transversely, the secondary hair germ has an asterisk-like
appearance (Figure 1.24). After the club hair has been shed from the follicle, the
secondary hair germ is sometimes referred to as the telogen germ unit.
The secondary hair germ (or telogen germ unit) is adjacent to the bulge zone
and the cornifying presumptive club. This places the hair papilla cells in close
proximity to the stem cells residing in the bulge zone. Below the hair papilla lies
the stela (collapsed fibrous root sheath; Figures 1.201.22).
Just above the secondary hair germ the telogen club is progressively
cornifying and expanding in a centrifugal fashion. Several layers of noncornified epithelium surround and tightly adhere to the cornifying club. As
telogen progresses, the cornified club expands to occupy the full width of the
follicle. This progressive cornification occurs over about a 3-month period, at the
end of which the hair shaft with its clubbed root is shed from the follicle (Figures
1.25 and 1.26). Like anagen hairs, telogen hairs may be large (terminal) or small
(vellus or miniaturized; Figure 1.27).
At the end of the telogen phase, shortly before or after the club hair is shed,
the stem cells of the follicular bulge are activated and form a population of
rapidly proliferating epithelium (transient amplifying cells). These cells
descend into the vacant and collapsed fibrous root sheath. Thus begins the
formation of a new anagen hair (Figure 1.28). A hair matrix is re-formed and the
various layers of the hair differentiate. The new anagen hair will continue to
produce a hair shaft for the next 27 years.
Figure 1.7 Isthmus of a terminal anagen hair. This zone is demarcated by the insertion of
the arrector pili muscle below and the opening of the sebaceous duct above. Original
magnification 100
PULLED, PLUCKED AND SPONTANEOUSLY SHED

HAIRS
Hairs that are shed or extracted from the scalp can be examined directly under
the microscope without any special processing. Covering the hairs with a few
drops of immersion oil and a second glass slide facilitates examination.
Normally, the only hairs that can be gently and easily pulled from the scalp are
telogen hairs. Any other type of hair that is easily removed from the scalp can be
regarded as abnormal. Examples of abnormal findings are the tapered, pencil
point hairs seen in chemotherapy, radiation therapy and alopecia areata (see
Chapter 28). Fragile hair shafts will fracture when gently pulled, and the fracture
can be identified at the proximal end of the shaft. In some highly inflammatory
scalp diseases, entire anagen hairs including their root sheaths can sometimes be
extracted. For example, this can occasionally be seen in lichen planopilaris.
Hairs can also be obtained from the scalp by forcibly plucking the shafts. In
this case a mixture of anagen and telogen hairs will usually be found. The
Figure 1.8 The inner root sheath (IRS) abruptly desquamates in the mid-portion of the
isthmus. Above this, the outer root sheath (ORS) cornifies without the formation of a
granular cell layer. Original magnification 400
process of plucking normal anagen hairs often leads to considerable artifactual

distortion. Often anagen hairs are extracted with one or both of the root sheaths
missing from the bulb. This sort of artifactual distortion should not be confused
with a pathological abnormality. A forcible hair pluck is usually performed to
determine the percentage of terminal telogen hairs (the trichogram).
Anagen pull/pluck findings
Normally, anagen hairs cannot be gently pulled from the scalp. They must be
forcibly plucked. It is pathological for anagen hairs to be easily and painlessly
extracted. Examples of this abnormality occur in loose anagen hair syndrome and
lichen planopilaris.
A plucked anagen hair is characterized by a pigmented bulb, which is often
expanded into a triangular, delta shape as it tears free from the hair papilla. The
hair papilla is usually (but not always) left behind in the dermis. Because the hair
Figure 1.9 Terminal anagen hair, infundibulum,vertical section. The outer root sheath
cornifies with the formation of a granular cell layer. The space between the hair shaft and
follicular wall is filled with desquamated keratinocytes, sebum, bacteria, pityrosporon and
cosmetics. Much of this debris is removed during processing. Original magnification
400
bulb is not cornified, it is soft and can take on a bent or hockey stick
configuration. Just above the bulb, portions of both an inner and an outer root
sheath can be identified. Unfortunately, the outer root sheath or both root sheaths
are often left behind in the dermis, an artifact of plucking. This gives the hair a
dysmorphic (not dystrophic) appearance (Figures 1.291.31).
Catagen pull/pluck findings
Like anagen hairs, catagen hairs are seldom gently pulled from the scalp. They
are sometimes found when a lock of hair is forcibly plucked from the scalp.
Plucked catagen hairs closely resemble telogen hairs, except that a clear, noncornified sac surrounds the club, and a tail of soft, clear tissue lies below the
bulb. This tail represents the degenerating epithelial column that lies between
the hair papilla and cornifying club (Figure 1.32).
Figure 1.10 Terminal anagen hair, infundibulum, transverse section. Section through the
lower infundibulum showing a granular cell layer. Original magnification 400
Figure 1.11 Terminal anagen hair, infundibulum, transverse section. The infundibula of
two normal, separate follicles have merged into a common infundibulum containing two
hair shafts. This is often a normal finding, especially in African-American patients, as in
this case. Original magnification 200
Telogen pull/pluck findings

Telogen hair shafts are easily pulled or plucked from the normal scalp. It is
estimated that the average person loses about 50 such hairs during the course of
the day. Pulled or plucked telogen hairs have an expanded, depigmented or
hypopigmented, club-shaped bulb. Because the entire telogen hair is cornified,
the bulb is not bent relative to the long axis of the shaft (Figures 1.33 and
1.34).
Trichogram findings
The forcible hair pluck, or trichogram, is a useful tool employed by some
clinicians who evaluate hair loss. A small lock of approximately 50 hairs is
grasped in a rubber-tipped surgical clamp, and the lock is quickly jerked out of
the scalp. The shafts are taped down to a glass slide, with the bulbs placed in the
Figure 1.12 Insertion of the arrector pili muscle into the follicle (bulge zone) in the
anagen phase. This portion of the follicle is home to the follicular stem cells, and is a
landmark demarcating the lower portion of the isthmus. Original magnification 400
center, and the hemostat is released. A few drops of immersion oil are dripped
onto the bulbs and a second glass slide or cover slip is placed on top. If the hair
is kinky or curly, the slides may need to be taped together so that the hairs lie
flat.
In theory, interpretation of the trichogram should be simple. The goal is to
obtain a telogen count, the percentage of telogen hairs represented in the
sample. However, considerable artifact may be introduced by the act of
plucking, and the anatomy of anagen hair bulbs may be badly distorted, making
some of them dysmorphic and difficult to identify. Hairs with bulbs that have
cleanly snapped off (as if cut) are counted as anagen hairs, as are bulbs that show
remnants of an outer or inner root sheath. A pigmented and bent bulb in the
absence of root sheaths can also be counted as an anagen hair. In this case, the
cuticle above the bulb will be ruffled (Figures 1.351.37).
BIBLIOGRAPHY
Headington J.Transverse microscopic anatomy of the human scalp. Arch Dermatol 1984;
120:44956
Lyle S, Christofidou-Solomidou M, Liu Y, Elder DE, Albelda S, Cotsarelis G. The C8/
144B monoclonal antibody recognizes cytokeratin 15 and defines the location of
human hair follicle stem cells. J Cell Sci 1998; 111:317988
Solomon A. The transversely sectioned scalp biopsy specimen: the technique and an
algorithm for its use in the diagnosis of alopecia. Adv Dermatol 1994; 9:12757
Sperling L.Hair density in African Americans. Arch Dermatol 1999; 135:6568
Sperling LC, Hair anatomy for the clinician (CME). J Am Acad Dermatol 1991; 25:117
Sperling LC, Lupton GP. The histopathology of non-scarring alopecia. J Cutan Pathol
1995;22:97114
Figure 1.13 The bulge zone, as seen with immunohistochemical markers for cytokeratin
15 and smooth muscle actin. The dark red staining of the outer root sheath, found in the
vicinity of the attachment of the arrector pili muscle, indicates the presence of cytokeratin
15. Cytokeratin 15 is a marker of the bulge zone. The brown staining of the arrector pili
muscle indicates the presence of smooth muscle actin. Photomicrograph courtesy of
George Cotsarelis, MD. Original magnification 100
Figure 1.14 Transverse section of a terminal anagen hair from an African-American. The
hair shaft is elliptical or kidney-bean-shaped, and is often eccentrically placed within the
surrounding epithelium. Original magnification 400
Figure 1.15 Terminal catagen hair, bulb, transverse section. A thin rim of pale-staining
epithelial cells, many with pyknotic nuclei, surround the hair papilla (P). The vitreous
layer (V) is markedly thickened. Original magnification 400
Figure 1.16 Terminal catagen hair, suprabulbar, transverse section. Numerous pyknotic
nuclei are present, and the markedly thickened vitreous layer (V) is clearly seen. Original
magnification 400
Figure 1.17 Terminal catagen hair, suprabulbar, transverse section, periodic acid-Schiff
(PAS) stain. PAS staining highlights the thickened vitreous layer. The fibrous root sheath
(F) is also much thicker than in an anagen hair. Original magnification 400
Figure 1.18 Terminal catagen hairs, suprabulbar, transverse sections. The follicle on the
right is sectioned just below the presumptive club hair where the epithelial column is
widest. The other is sectioned through the presumptive club, which is just beginning to
cornify centrally Original magnification 200
Figure 1.19 Lower half of a terminal catagen hair, vertical section. The bulb (B;
corresponding to Figure 1.15), disintegrating epithelial column (EC; corresponding to
Figure 1.16) and presumptive club (PC; corresponding to Figure 1.18, left side) can be
seen. Original magnification 200
Figure 1.20 Vertical section of the stela (or streamer) below the bulb of a catagen hair.
The stela is the collapsed fibrous root sheath found below hairs in the catagen/telogen
phase or hairs that have miniaturized. Original magnification 200
Figure 1.21 Vertical section of the stela, as in Figure 1.20. Original magnification 400
Figure 1.22 Transverse section of three stelae, demonstrating their roughly circular shape
and numerous small vascular spaces. Original magnification 400
Figure 1.23 Bulb of early telogen hair, vertical section. The hair papilla is seen as a tight
cluster of nuclei lying just below the nipple-like secondary hair germ (SHG; the telogen
germ unit, seen also in Figure 1.24). Original magnification 400
Figure 1.24 Secondary hair germ (SHG) or telogen germ unit, transverse section. Just
below this structure lies the hair papilla. Just above lies the cornifying club of the
telogen hair (if it has not yet been shed). A terminal anagen hair (A) is nearby for
comparison. Original magnification 400
Figure 1.25 Transverse section of an early telogen hair bulb. The cornifying clubs
serrated rim interdigitates with the surrounding envelope of outer root sheath epithelium.
Original magnification 400
Figure 1.26 Bulb of a late telogen follicle, transverse section. The cornified club now fills
most of the width of the follicle, with only a thin rim of non-cornified epithelium
remaining. The club hair is now ready to be shed. Original magnification 400
Figure 1.27 Section through the bulbs of a terminal telogen hair and a vellus telogen hair.
Figure 1.28 Newly growing anagen hair, extending down from the bulge zone. The
telogen club hair has not yet been shed. Original magnification 100
Figure 1.29 Bulb of forcibly plucked, terminal anagen hair. Original magnification 200
Figure 1.30 Suprabulbar zone of forcibly plucked, terminal anagen hair (IRS, inner root
sheath; ORS, outer root sheath; F, fibrous root sheath). Original magnification 200
Figure 1.31 Dysmorphic, plucked terminal anagen hair. Here the term dystrophic should
not be applied, because the loss of the root sheaths is not a growth defect but merely an
artifact of plucking. Original magnification 100
Figure 1.32 Forcibly plucked catagen hair. The tail-like remnant of the degenerating
epithelial column is found just below the presumptive club. Original magnification 200
Figure 1.33 Forcibly plucked early telogen hair. A noncornified epithelial sac surrounds
the cornifying club. Original magnification 200
Figure 1.34 Forcibly plucked or gently pulled late telogen hairs. The clubs are completely
cornified and the epithelial sac is gone. Original magnification 200
Figure 1.35 Forcibly plucked lock of hairsthe trichogram. In this field of 23 terminal
hairs, 21 anagen hairs and two telogen hairs are present. The telogen count is therefore 2/
23, or about 9%. Original magnification 40
Figure 1.36 Snapped-off shaft, an artifact of plucking. A telogen hair (upper hair) and a
snapped-off shaft are found in this field. When deeply rooted, terminal anagen hairs are
plucked, a clean transverse break in the shaft, as seen here, is sometimes the result. Shafts
such as these can be counted as anagen hairs. Original magnification 200
Figure 1.37 Dysmorphic, terminal anagen hair, an artifact of plucking. Sometimes when
a terminal anagen hair is plucked, the entire shaft is removed but the root sheaths are left
behind in the scalp. The pigmented, bent root (often resembling a hockey stick) and the
ruffling of the cuticle of the proximal shaft identify such a hair as an anagen hair. A
similar hair is seen in Figure 1.31. Original magnification 200
CHAPTER 2
Specimen acquisition, handling and
processing
ACQUISITION
Selecting the biopsy site is the most difficult and important part of the process.
The most fruitful site will vary depending on the disease, and often the clinician
is uncertain of the diagnosis. Sampling the center of a lesion of alopecia areata or
trichotillomania would be appropriate. Sampling the bald center of a lesion of
scarring alopecia is seldom useful, and the active peripheral margin would be a
more suitable target. Compounding the difficulty of site selection is sampling
error. Clinicians cannot see below the surface of the skin, and even the most
experienced physician may choose an unrewarding spot. If a recently involved
area of scalp showing early clinical changes is selected, the diagnostic yield will
be higher. Highly inflamed sites (pustules or papules) are often very advanced
lesions and are frequently non-diagnostic. Multiple separate specimens chosen
from several sites in or around the lesion will increase the diagnostic yield.
However, clinicians may not have the luxury of obtaining multiple specimens.
In some cases the patients normal scalp can serve as a basis for comparison
with the abnormal scalp. For example, a specimen from the mid-occiput can help
establish a diagnosis of common balding in a patient with hair loss on the crown.
Once the site is selected, it should be anesthetized with lidocaine with
epinephrine (adrenaline). A generous amount of anesthetic (13 ml) should be
injected into the deep dermis and superficial fat, and allowed to act for 1530
minutes before the biopsy is performed. This will minimize bleeding.
The blade of the punch biopsy tool should extend through the dermis down
into the fat, so that intact bulbs of deeply rooted terminal hairs can be removed.
A 4-mm biopsy wound can be easily closed with 30 suture because the
needle can traverse the wound in a single pass. A suture color that contrasts with
the patients hair will assist in suture removal 1 week after the biopsy is
performed.
SPECIMEN ACQUISITION, HANDLING AND PROCESSING 33
HANDLING
Once obtained, the scalp biopsy specimen should be allowed to fix in formalin
for at least 24 hours before sectioning. Biopsy specimens obtained for direct
immunofluorescence testing should of course be placed in the appropriate
transport solution.
PROCESSING
The required tools include a sharp blade, a blade holder, a pair of fine-toothed
forceps, marking ink, a cotton-tipped applicator and the standard plastic
specimen cassette. Sponges should be used inside the cassette to prevent the thin
slices of tissue from escaping. The sharpest blade for the job is a disposable,
flexible shaving blade (blue blade). These can easily be snapped in half for
economy and safety (Figure 2.1). The author prefers to use red marking ink, but
Figure 2.1 Tools for performing transverse sections. The flexible shaving blade has been
snapped in half
Figure 2.2 The specimen is placed on its side like a cylindrical loaf of bread, and is gently
stabilized with forceps. A flexible, disposable shaving blade is ideal for taking the slices
any color will do. A specially colored cassette will alert the histology technician
that embedding must be performed in a particular way.
There are several ways to slice the tissue into transverse sections. The
technique used by Headington and Whiting involves a single transverse slice
about 1 mm below the epidermal surface. Both cut sides of the specimen are
embedded down in the cassette. As the microtome cuts deeper into the tissue
block, the sections become progressively more superficial in one half of the
specimen and deeper in the other. Simply sectioning deeper into the block allows
one to obtain sections as superficial or as deep as required.
An alternative method is that of Frishberg and Sperling. One treats the biopsy
specimen like a cylindrical loaf of bread, and cuts it into three or four slices
(Figures 2.2 and 2.3). The slices are about 1 mm thick. The deep surface of
each slice is inked (Figure 2.4) and the inked sides are placed down in the
cassette. Once the ink has been removed by the microtome, a single section is
taken. In this way, the specimen is sampled at several different depths
(Figure 2.5). Because only a single section is needed to view multiple levels on a
SPECIMEN ACQUISITION, HANDLING AND PROCESSING 35
Figure 2.3 The specimen is cut into three or four slices, which are placed with the cut
surfaces up, so that they are ready for inking
Figure 2.4 The inked slices are placed in a cassette, packed between sponges. They will
be embedded in paraffin, ink side down
single slide, the remainder of the tissue in the block is available for recuts and
special stains.
Yet another but more tedious method involves embedding the epidermal and/or
fat end down in the cassette, and taking multiple horizontal sections through the
entire specimen. Dozens of sections can be required to section through the entire
block, and the block is exhausted in the process. However, every possible level
of every follicle in the specimen can be carefully studied, and this technique is
useful for research purposes.
BIBLIOGRAPHY
Frishberg DP,Sperling LC,GuthrieVM. Transverse scalp sections: a proposed method for
laboratory processing. J Am Acad Dermatol 1996; 35:2202
Headington J. Transverse microscopic anatomy of the human scalp. Arch Dermatol 1984;
120:44956
Figure 2.5 The final product is a single slide containing disks of tissue from multiple
levels (superficial to deep)
Whiting DA. Diagnostic and predictive value of horizontal sections of scalp biopsy
specimens in male pattern androgenetic alopecia. J Am Acad Dermatol 1993; 28:
75563
Whiting DA, Howsden FL Color Atlas of Differential Diagnosis of Hair Loss. Cedar
Grove, NJ: Canfield Publishing, 1996
CHAPTER 3
Evaluating and describing transverse
(horizontal) sections
THE RATIONALE OF TRANSVERSE/ HORIZONTAL

SECTIONING
Most specimens obtained for the diagnosis of hair loss should be sectioned
transversely (horizontally). The technique of transverse sectioning is unfamiliar
to many pathologists, and so it will be useful to discuss its rationale. Vertical
sections are of limited value in the study of hair disease because the number and
type of hairs found on a vertical section are subject to considerable sampling
error. The information obtained from vertical sections is usually incomplete and
often misleading, as demonstrated in Figure 3.1. A vertical section bisecting the
specimen through plane X would sample only four follicles out of a total of 28
contained in the specimen. A section through plane Y would not sample any
follicles. In many cases of alopecia, the diagnosis hinges on just a few follicles.
The chance of hitting these follicles on a routine vertical section is slim.
Accurately counting follicles is nearly impossible using vertical sections, so
quantitative data cannot be gleaned in this way.
Transverse/horizontal sectioning ensures that all follicles in the specimen are
counted and examined, at multiple levels, with just a few sections. Pathologists
and dermatologists who have been disappointed with the results of vertically
sectioned hair biopsy specimens are truly gratified when transverse sectioning is
employed.
THE PATHOLOGISTS CHECKLIST FOR
EVALUATING SCALP BIOPSY SPECIMENS
The pathologist can employ a checklist to avoid missing important information.
The order of the checklist is a matter of personal preference, but the pertinent
items that must be addressed before arriving at a diagnosis include:
(1) What is the specimen diameter (e.g., 4 mm)? This information is required to
determine whether the number of follicles is normal or decreased.
Figure 3.1 A vertical section bisecting the specimen through plane X would sample
only four follicles out of a total of 28 contained in the specimen. A section through plane
Y would not sample any hairs
(2) Are follicular units evenly spaced, or are there blank spots with an absence
of follicles, suggesting scarring or severe miniaturization (Figures 3.2 and
3.3)?
(3) Do most follicular units contain two to six follicles, with large follicles
outnumbering small follicles (Figure 3.4)
(4) Are a normal number (> 85%) of the terminal follicles in the anagen phase
(Figure 3.5)?
(5) Do any follicles show incomplete or distorted anatomical features
(Figure 3.6)?
(6) Is inflammation present, and at what level of the follicle (bulb, suprabulbar,
isthmus, infundibulum)?
(7) Is perifollicular fibrosis present; have individual follicles been entirely
replaced by connective tissue (true follicular scars; Figure 3.7)?
(8) What is the total number of viable follicles in the specimen? The total
number of terminal anagen hairs? The total number of vellus hairs?
The information gleaned from this evaluation will be used to compose the
microscopic description. Interpreting the data and arriving at a final diagnosis is
more challenging, and the major purpose of this text is to assist in this process.
With few exceptions, the diagnosis of most forms of alopecia hinges on a
constellation of findings and not on a single finding. The group of findings
typical of each disease is described in the chapters devoted to particular entities.
THE NORMAL SCALP IN TRANSVERSE SECTION
The architecture of a transversely sectioned biopsy specimen is quite
predictable, and numerical data from the study of normal scalp specimens are
available. Most data are based on 4-mm punch biopsy specimens, which can be
considered the standard. A specimen 4 mm in diameter samples a surface area
EVALUATING AND DESCRIBING TRANSVERSE (HORIZONTAL) SECTIONS 39
Figure 3.2 Example of blank spots in the follicular architecture, suggesting loss of
follicles. The zones of follicular loss are quite obvious because of the tinctorial difference
between follicular and non-follicular dermal collagen. Original magnification 40
Figure 3.3 Multiple follicles are missing and have been replaced by normal-appearing
dermal collagen. Superficial levels assessed on this specimen confirmed a marked
reduction in total follicular numbers. Original magnification 100
of 12.6 mm2 = r2. This formula can be used to compare data from punch
biopsies larger or smaller in diameter with those of a 4-mm punch. For example,
a 3-mm punch biopsy specimen has a surface area of 7.07 mm2.
In a 4-mm punch biopsy specimen from a Caucasian, there should be about 33
terminal hairs in a transverse section through the deep dermis (Figure 3.8).
Sectioning through the upper dermis will reveal about five additional vellus hairs
(Figure 3.9). The average scalp biopsy specimen will therefore contain about
38 follicles. Considerable individual variation exists and the range of normal is
quite broad; total hair counts as low as 19 and as high as 59 have been recorded.
On average, two of the terminal hairs will be in the telogen phase, and 31 will be
in the anagen phase. The telogen count (number of terminal telogen hairs divided
by the total number of terminal hairs) will therefore be about 2/33=6%.
Considerable individual variation exists for telogen counts among normal
individuals, and figures within a range of 015% (based on histological sections)
can be considered normal.
Figure 3.4 Transverse section through the upper dermis of a specimen from a normal
scalp. Two follicular units are shown, the one on the left containing one terminal and two
vellus hairs, and the one on the right containing three terminal hairs. Although the first
unit may not appear normal because vellus outnumber terminal hairs, all the follicular
units need to be assessed to make a conclusion about overall normality. Original
magnification 100
Figure 3.5 In this field, only two of five terminal follicles (40%) are in the anagen phase.
This would be clearly abnormal if it were representative of the entire specimen. Original
magnification 100
On the average, black patients of African descent have fewer, although larger,
follicles than white patients (Figures 3.10 and 3.11). The average number of
follicles for African Americans, based on 4-mm biopsy specimens, is 21 (18
terminal and three vellus follicles) with an average telogen count of 7%. The
percentage of catagen and/or telogen hairs can prove to be an important
diagnostic feature in many forms of hair loss. Catagen and telogen hairs have
the same diagnostic significance, since all catagen hairs become telogen hairs
within a few weeks. For the sake of simplicity, these two phases can be grouped
together as the catagen/telogen phase. In this textbook, the term catagen/telogen
phase will be used to refer to hairs in either the catagen or the telogen phase. For
diagnostic purposes, it is not important to differentiate between catagen and
telogen hairs, but just to recognize a follicle as being in either phase. Catagen
Figure 3.6 Distorted follicular anatomy, in this case due to forcible plucking of the hair
shaft prior to taking the biopsy specimen. The shaft and a portion of the inner root sheath
are missing, and the epithelium has collapsed inward. Original magnification 400
Figure 3.7 True follicular scars, diagnostic of a scarring alopecia. In transverse section,
they appear as discrete, circular or oval structures composed of compact and concentric
collagen bundles. Original magnification 400
hairs can be included with the telogen hairs when determining the telogen count
(Figure 3.12).
In the superficial fat and lower dermis, home to the bulbs and suprabulbar
zones of terminal anagen hairs, the follicles are spaced apart fairly evenly.
However, in the mid- and upper dermis, groups of follicles become segregated into
follicular units. Each follicular unit contains about two to five terminal hairs and
zero to two vellus hairs (Figure 3.13). A shortcut for assessing numerical
normality is by looking at individual follicular units (Figure 3.14). If each unit
contains two to five terminal hairs (outnumbering vellus hairs), and most units
are similar, then the number and size of hairs are probably normal. As would be
expected, the number of terminal hairs per follicular unit is smaller in African
Americans than in Caucasians.
The average density of follicular units is about 1/mm2 surface area. Therefore,
a horizontal section 4-mm in diameter (12.6 mm2) will contain about 12
follicular units.
Figure 3.8 Transverse section from normal scalp skin (Caucasian) at the level of the
superficial fat. Only terminal follicles can be found at this level, and they are not yet
organized into follicular units. Original magnification 40
Figure 3.9 Transverse section from normal scalp skin (Caucasian) at the level of the
upper dermis. The bulbs of telogen hairs and vellus hairs can also be found at this level,
organized into follicular units. Original magnification 40
In the normal scalp, the terminal: vellus hair ratio should be 2:1 or greater. If
biopsy specimens from the crown and occiput of the same person are compared,
they should be similar in terms of follicular size, number and percentage of
anagen/telogen hairs. The architecture of scalp biopsy specimens should be
uniform over
Table 3.1 Template for a hair biopsy report
Accession number:
Date:
Patient name/age/sex/race:
Submitting physician:
Clinical impression:
Macroscopic description: biopsy diameter/location on scalp
(e.g. 4-mm punch biopsy, vertex of scalp):
Microscopic description of vertical sections:
Microscopic description of horizontal sections:
Figures 3.10 Transverse section from normal scalp skin (African American) at the level
of the deep dermis. Normally, only terminal and indeterminate follicles can be found at
this level, and they are not yet organized into follicular units.This specimen contained 16
total follicles. Original magnification 40
Figure 3.11 Another transverse section from normal scalp skin of an African American,
containing 22 follicles. These numbers would be regarded as low for a Caucasian but are
normal in African Americans. Original magnification 40
Terminal anagen hairs:
Terminal catagen hairs:
Terminal telogen hairs:
Telogen germinal units:
Vellus hairs:
Total hairs (terminal plus vellus, all phases):
Anagen : telogen percentages (e.g. 85% : 15%):
Terminal: vellus ratio (e.g. 3:1):
Follicular units:
Follicular stelae:
Lymphohistiocytic infiltrate:
Upper follicle:
Lower follicle/bulb:
Fibrosis:
Comments:
Figure 3.12 Transverse section through the level of the dermal-subcutaneous junction. In
this particular field, there are 12 terminal anagen hairs and seven terminal telogen hairs,
for a total of 19 terminal hairs. The telogen count for this field would therefore be 7/
19=37%. Original magnification 40
Figure 3.13 Normal follicular unit. This unit contains four terminal hairs and one vellus
hair. Original magnification 100
DIAGNOSIS:
Consultants:
Pathologists signature_________________
the entire scalp, with the possible exception of the fringes.

Mild upper dermal perifollicular inflammation may be present even in normal
scalp specimens. This is especially true for African American patients.
REPORTING HISTOLOGICAL FINDINGS -THE
BIOPSY REPORT
Transverse sectioning allows the pathologist to gather a considerable amount of
data about the specimen. This can be summarized in a microscopic description
(e.g. A reduced number of hairs are present, and most are miniaturized).
Figure 3.14 Two follicular units from normal scalp skin. One unit contains three terminal
anagen hairs and the other contains one terminal anagen and one vellus telogen hair. Even
within the same specimen, the number of hairs per follicular unit varies somewhat; so
several units need to be examined to arrive at a valid average. Original magnification
100
Alternatively, detailed data can be presented in tabular form. A template for a

complete report, adapted from that used by David A.Whiting, MD, is presented
in Table 3.1. Such a detailed report not only serves as the basis for the final
diagnosis, but also allows for efficient data collection for research purposes.
BIBLIOGRAPHY
Headington J. Transverse microscopic anatomy of the human scalp. Arch Dermatol 1984;
120:44956
Sperling L. Hair density in African Americans. Arch Dermatol 1999; 135:6568
Sperling LC. Hair anatomy for the clinician. J Am Acad Dermatol1991; 25:117
Sperling LC, Lupton GR The histopathology of non-scarring alopecia. J Cutan Pathol
1995; 22:97114
specimens in male pattern androgenetic alopecia. J Am Acad Dermatol 1993; 28:
75563
Whiting DA, Howsden FL. Color Atlas of Differential Diagnosis of Hair Loss. Cedar
Grove, NJ: Canfield Publishing, 1996
CHAPTER 4
Classif ication of hair disease
Various classification schemes for alopecia exist, but all are imperfect. Most
forms of alopecia demonstrate at least some overlapping clinical and histological
features. This overlap blurs the distinction between diseases, making
classification difficult. It would make the most sense to segregate diseases by
etiology, but the causes of many forms of hair loss are unknown, making it
difficult to group diseases with confidence.
CICATRICIAL (SCARRING) VS. NON-CICATRICIAL
ALOPECIA
The most common classification system divides the diseases into cicatricial
(scarring) and non-cicatricial (non-scarring) forms of alopecia. In this textbook,
the terms cicatricial and scarring will be considered to be synonymous and
will be used interchangeably. Cicatricial or scarring implies that follicular
epithelium has been replaced by connective tissue. However, in some cases of
alopecia, follicles seem simply to disappear without noticeable alteration in
tissue architecture. The broadest definition of scarring alopecia might include all
forms of alopecia in which hair follicles are permanently lost. In contrast, nonscarring alopecia is potentially reversible.
However, certain hair diseases demonstrate a biphasic pattern, where nonscarring hair loss is seen early in the course of the disease, and permanent hair
loss becomes apparent in the later stages of the disease (Figure 4.1). Examples
of diseases demonstrating this biphasic pattern include androgenetic alopecia,
alopecia areata and traction alopecia. These forms of alopecia are generally
considered to be non-scarring. However, after many years or decades of
continuous active disease, permanent dropout of follicles occurs.
CLASSIFICATION OF CICATRICIAL (SCARRING)
ALOPECIA
This classification is especially confusing and controversial. There are no
characteristic biological markers for most forms of scarring alopecia. We do not
know whether the clinical and histological features found in a given patient are
47
Figure 4.1 The biphasic form of alopecia. With the passage of time, follicles begin to
disappear permanently and histological specimens take on the appearance of a cicatricial
alopecia
manifestations of a distinct disease, or just individual host responses. Any

classification of scarring alopecia should be considered provisional and subject
to change as new information becomes available.
Scarring alopecia can be subdivided into two categories. The first is primary
scarring alopecia, where the target of inflammation appears to be the follicle. In
secondary scarring alopecia, the follicle is merely an innocent bystander in the
disease process, and is destroyed in a non-specific manner. Examples of
secondary scarring alopecia include deep burns, radiation dermatitis, cutaneous
Figure 4.2 Classification of scarring alopecia. The ovals in this diagram overlap for
several reasons. First, a diagnostic entity may share at least some clinical and/or
histological features with another form of cicatricial alopecia. Second, it is possible that
two different entities may some day prove to be variations of the same disease (this
concept is discussed in Chapter 23). Finally, the overlap of these distinct entities serves
as an admission that the conditions are poorly understood, and that their separation in this
classification is provisional. LPP, lichen planopilaris (FFA, frontal fibrosing alopecia is a
subset of LPP); CCLE, chronic,cutaneous lupus erythematosus;CCSA,central,centrifugal
scarring alopecia; AKN, acne keloidalis
malignancies, cutaneous sarcoid, sclerosing dermatoses such as morphea and

necrobiosis lipoidica, and certain chronic infections such as cutaneous
tuberculosis. The various forms of secondary scarring alopecia should have
distinctive histological features typical of the underlying disease. For example,
alopecia caused by cutaneous sarcoidosis should reveal sarcoidal granulomata in
the dermis. A discussion of the various forms of secondary scarring alopecia is
beyond the scope of this text.
Primary scarring alopecia can be divided into six diagnostic groups
(Figure 4.2). They are:
(1)
(2)
(3)
(4)
(5)
(6)
Central, centrifugal scarring alopecia;

Lichen planopilaris;
Chronic, cutaneous lupus erythematosus (discoid lupus erythematosus);
Acne keloidalis (folliculitis keloidalis; acne keloidalis nuchae);
Dissecting cellulitis (perifolliculitis abscedens et suffodiens);
Scarring alopecia, not otherwise classified.
This short list is a simplification of a longer list of confusing, vague and poorly
defined diagnostic terms that have been coined and used by various authors
during the past century. Notably absent from the above list are terms such as
pseudopelade, pseudopelade of Brocq, folliculitis decalvans, tufted folliculitis
and a variety of other more obscure terms. These entities are poorly defined, and
49
their nomenclature is used in various ways by different authors and clinicians.

Almost all of these older terms can be incorporated into one of the six categories
shown in Figure 4.2. Nevertheless, many of the older terms will be discussed in
this text for the sake of clarity.
BIBLIOGRAPHY
Elston DM, Bergfeld WF. Cicatricial alopecia (and other causes of permanent alopecia).
In Olsen EA, ed. Disorders of Hair Growth. New York: McGraw-Hill, 1994:
285314
Laymon CW. The cicatricial alopecias. J Invest Dermatol 1947; 8: 99122
Sperling L, Solomon A,Whiting D. A new look at scarring alopecia. Arch Dermatol 2000;
136:23542
Templeton S, Solomon A. Scarring alopecia: a classification based on microscopic
criteria. J Cutan Pathol 1994; 21: 97109
CHAPTER 5
Distinctive or critical histological features
and associated diseases
Classification schemes are of little value to pathologists trying to extract the

diagnosis from a glass slide. The histological features, in conjunction with a brief
clinical description, must somehow guide the pathologist to the correct
diagnosis. To assist in this process, some especially important histological
features (listed below) will help to segregate the diagnostic entities. Identifying
additional histological features will make it easier to establish the diagnosis.
Frequently, different diseases may share two or more histological features. When
this occurs, separating such diseases may rest on good clinical correlation or
subtle histological clues.
Attempts have been made to create alopecia algorithms for arriving at a
diagnosis, but in the authors experience, such algorithms provide little
assistance. The starting point for arriving at a histological diagnosis is
recognition of an obvious or dominant histological finding, such as
miniaturization of hairs, missing hairs, or perifollicular inflammation.
Unfortunately, no single histological feature is sufficient to establish a definitive
diagnosis in any form of hair loss. However, a differential diagnosis based on
one or two histological features will help to create a short list of possible
diagnoses. Additional histological features characteristic of the entities on the
short list can then be used to narrow the field of possibilities. Clinical
information will often help to decide the issue. Listed below are histological
features, and those diseases that often demonstrate the feature.
DECREASED HAIR DENSITY
This is determined by counting the total viable follicles/mm2 (Figures 5.1 and
5.2).
Cicatricial alopecia (all forms)

Congenital hypotrichosis (various syndromes)
End stage traction alopecia (an example of the biphasic pattern of hair loss)
Androgenetic alopecia or hereditary balding (very long-standing disease; an
example of the biphasic pattern of hair loss)
DISTINCTIVE OR CRITICAL HISTOLOGICAL FEATURES AND ASSOCIATED DISEASES

51
Figure 5.1 An example of normal hair density. A transverse section from the normal
(uninvolved) scalp of an African American woman with traction alopecia. The section
contains 22 follicles, slightly more than average. Original magnification 40
Figure 5.2 An example of decreased hair density from the same woman as in Figure 5.1.
A section from the zone of alopecia contains 11 follicles, a marked reduction compared to
her normal scalp. Original magnification 40
Alopecia areata (very long-standing disease; an example of the biphasic

pattern of hair loss)
Aplasia cutis congenita
DECREASED HAIR DENSITY AT THE LEVEL OF THE

LOWER DERMIS
This is determined by counting only at this level.
Telogen effluvium
Traction alopecia
Figure 5.3 In this specimen from a patient with alopecia areata (and that in Figure 5.4), the
clinician took the biopsy from a bald spot, but normal or nearly normal numbers of
follicles were present. This can be explained by an increase in miniaturized hairs
producing no hair shaft. Original magnification 40
All forms of cicatricial alopecia

Alopecia areata (long-standing disease)
Note: hair density in dark-skinned, kinky-haired individuals (e.g., many African
Americans) is lower than in Caucasians.
NORMAL HAIR DENSITY DESPITE A CLINICAL
REDUCTION IN THE AMOUNT OF HAIR
Here, there is a discrepancy between the clinical impression of marked hair loss
and the histological finding (total viable follicles/mm2) of numerous hairs
Telogen effluvium (catagen/telogen increased)

53
Figure 5.4 As in the patient in Figure 5.3, this specimen was taken from a bald spot of
alopecia areata, but normal or nearly normal numbers of follicles were present. In this
case it was because of a massive conversion to telogen hairs. Original magnification 100
Figure 5.5 Miniaturized hairs in a patient with temporal triangular alopecia. Average
hair shaft diameter is 0.02 mm. Original magnification 200
Figure 5.6 Normal hairs from the same patient as in Figure 5.5 (normal, perilesional
skin). Average shaft diameter is 0.12 mm. Original magnification 200
Trichotillomania (catagen/telogen increased)

Androgenetic alopecia/hereditary balding (miniaturized hair increased)
Figure 5.7 Increased percentage of catagen/telogen hairs in a patient with telogen

effluvium. The majority of hairs are terminal (large) hairs, but when all follicles are
counted, 30% are in the catagen/telogen phase. Original magnification 40
Figure 5.8 Higher power view of specimen shown in Figure 5.7. Original
magnification 100
Alopecia areata (miniaturized/telogen hairs increased)

Temporal triangular alopecia (miniaturized hair increased)
Loose anagen hair syndrome (catagen/telogen increased)
Most hair shaft disorders
MINIATURIZATION OF HAIRS
See Figures 5.5 and 5.6.
Androgenetic alopecia/hereditary balding

Alopecia areata
Patchy hair loss in systemic lupus erythematosus
Patchy or diffuse hair loss in secondary syphilis

55
Figure 5.9 In this patient with alopecia areata, the lower half of a follicle is affected by
lymphocytic inflammation. Original magnification 400
Figure 5.10 The upper half of the follicle in Figure 5.9. This half is spared lymphocytic
inflammation. Original magnification 400
INCREASED PERCENTAGE OF CATAGEN AND/OR

TELOGEN HAIRS
See Figures 5.7 and 5.8. Note: as mentioned earlier, the diagnostic significance
of catagen and telogen hairs is the same, since all catagen hairs become telogen
hairs within a few weeks. Therefore, follicles in either of these two phases can be
referred to as catagen/telogen hairs.
Trichotillomania
Traction alopecia (acute)
Telogen effluvium
Alopecia areata
Androgenetic alopecia/hereditary balding (affected area only)
Figure 5.11 In this example of lichen planopilaris, lymphocytic inflammation is

concentrated around the upper half of the follicle. Vacuolar, basilar degeneration is
present. Original magnification 400
Figure 5.12 In this example of central, centrifugal scarring alopecia, chronic

inflammation is concentrated at the level of the isthmus and lower infundibulum.
There is perifollicular fibroplasia but not vacuolar interface alteration. Original
magnification 200
Patchy hair loss in systemic lupus erythematosus

Patchy hair loss in secondary syphilis
Inflammatory, cicatricial alopecia
INFLAMMATION PREDOMINANTLY INVOLVING
THE LOWER HALF OF THE FOLLICLES
Alopecia areata (predominantly lymphocytic)
Patchy hair loss in systemic lupus erythematosus (predominantly lymphocytic)
Patchy hair loss in secondary syphilis (predominantly lymphocytic with
occasional plasma cells)

57
Figure 5.13 A section through the same follicle as in Figure 5.12, but at the level of
the dermal/fat junction. Inflammation spares the lower half of the follicle (but
premature desquamation of the inner root sheath is present). Original magnification
200
Figure 5.14 In this example of inflammatory scarring alopecia, there are blank spots
with residual inflammation, representing the sites of former follicles and follicular
units. The sebaceous glands have disappeared with the follicles. Original
magnification 40
Dissecting cellulitis/perifolliculitis capitis abscedens et suffodiens (dense,

mixed acute and chronic inflammation)
INFLAMMATION PREDOMINANTLY INVOLVING
THE UPPER HALF OF THE FOLLICLES
With vacuolar interface alteration
See Figure 5.11.
Lichen planopilaris
Frontal, fibrosing alopecia
Chronic, cutaneous (discoid) lupus erythematosus
Figure 5.15 The same specimen as in Figure 5.14. Original magnification 100
Figure 5.16 In this example of end-stage traction alopecia, all terminal hairs have
disappeared, but sebaceous glands are spared. Original magnification 100
Without vacuolar interface alteration

Acne keloidalis
Central, centrifugal scarring alopecia (also known as follicular degeneration
syndrome and pseudopelade)
FOLLICULAR DROPOUT (REPLACEMENT OF

FOLLICLES BY CONNECTIVE TISSUE)
With loss of associated sebaceous glands
Cicatricial alopecia: all forms

59
Figure 5.17 In this specimen from a patient with central, centrifugal scarring alopecia
there is a follicle whose inner root sheath has desquamated well below the isthmus
(follicle at lower left). Normal follicles with intact inner root sheaths are present for
Figure 5.18 An enlargement of the abnormal hair found in Figure 5.17. Original
magnification 400
With associated sebaceous glands intact

See Figure 5.16.
Traction alopecia (end stage)
Androgenetic alopecia (very advanced and long-standing)
Alopecia areata (very advanced and long-standing)
PREMATURE DESQUAMATION OF THE INNER

ROOT SHEATH
Figure 5.19 Trichomalacia is evident in this specimen from a patient with

trichotillomania. The hair shaft is distorted in shape, irregularly pigmented and
incompletely cornified. Original magnification 200
Central, centrifugal scarring alopecia (also known as follicular degeneration

syndrome and pseudopelade)
Acne keloidalis (occasionally)
TRICHOMALACIA
See Figure 5.19.
Trichotillomania
Acute traction alopecia
Pressure-induced alopecia
Alopecia areata
CHAPTER 6
Clinical correlation
Clinicians who contribute even a brief clinical description and differential

diagnosis are of considerable assistance to the pathologist. Some clinical features
that may be described include:
Pattern of hair loss

Evidence of inflammation
Evidence of hair breakage (hairs of uneven length)
Evidence of permanent hair loss
Obliteration of follicular ostia
Abnormal hair density
The most important feature is the pattern of hair loss. Hair loss can be diffuse or
patterned. Patterned hair loss implies that the area of alopecia is confined to
one or several portions of the scalp, leaving at least a portion of the scalp
uninvolved. Truly diffuse hair loss suggests a uniform reduction in hair density
over all portions of the scalp. Telogen effluvium (Figure 6.1) is an example of
truly diffuse alopecia, with all areas of the scalp showing some thinning of the
hair. Patchy alopecia areata is one example of patterned alopecia. The various
patterns of thier loss are listed below.
PATTERNS OF HAIR LOSS
Truly diffuse hair losse.g., telogen effluvium, alopecia totalis in evolution,
chemotherapy/radiation therapy
Diffuse hair loss over crown/vertex with relative sparing of parietal/occipital
arease.g., androgenetic alopecia
Nearly total hair loss with loss of follicular ostia, centered on crown or vertex
e.g., central centrifugal scarring alopecia
Patches of hair loss with bizarre or geometric shapese.g., trichotillomania
Randomly scattered oval or circular patches of complete hair losse.g.,
alopecia areata
Figure 6.1 An example of truly diffuse hair loss (telogen effluvium). Hair thinning is
uniform over the crown, occiput and sides of the head
Randomly scattered, irregularly shaped patches of partial or complete hair loss

e.g., lichen planopilaris
Marked thinning of both templese.g., burnt out traction alopecia
Small, geometric patches of hair loss of anterior margin of temple (unilateral
or bilateral)e.g., temporal triangular alopecia
Androgenetic alopecia has been described as being both diffuse and patterned.
Although on rare occasions the balding process seems to affect the entire scalp,
including the occiput, in the vast majority of cases the crown of the scalp
(including frontal and vertex regions) is predominandy involved. Therefore, the
condition has a distinctive pattern of thinning (Figures 6.2 and 6.3).
Hair shaft disorders associated with hair fragility, such as trichorrhexis nodosa,
tend to cause localized zones of alopecia containing hairs of uneven length.
When the hair is particularly fragile, as is true in monilethrix, patches of hair
stubble will be found. In disorders caused by hair shaft fragility, the shaft defect
is usually readily apparent under the light microscope. In trichotillomania, the
patches of alopecia are seldom totally bald. Usually there are several short hairs
of varying lengths scattered over the involved area.
Clinicians should examine the scalp surface in all cases of hair loss.
Abnormalities may or may not be related to the hair loss but need to be
documented. Erythema, pustules, follicular papules and perifollicular scaling or
hyperpigmentation suggest an inflammatory form of alopecia. Wide spacing
between follicles, clusters of shafts exiting single follicular ostia (polytrichia or
tufting) and the obliteration of follicular openings are all signs of scarring
alopecia. Follicular plugging, with dilated ostia devoid of hair shafts, can be
another indication of follicular destruction, as seen in discoid lupus
erythematosus. Marked erythema and scaling or numerous papular lesions
without a loss of follicular density suggests a primary scalp disorder (as opposed
to a hair disorder). Psoriasis, seborrheic dermatitis and Langerhans cell
63
Figure 6.2 An example of patterned hair loss in a woman with androgenetic alopecia. The
crown is diffusely and symmetrically affected with relative sparing of the occiput as seen
in Figure 6.3
histiocytosis (histiocytosis X) of the scalp can cause dramatic scalp disease with
little effect on hair density.
BIBLIOGRAPHY
Sperling LC. The evaluation of hair loss. Curr Probl Dermatol 1996; 8:99136
Sperling LC, Mezebish DS. Hair diseases. Med Clin North Am 1998; 82:115569
Figure 6.3 Occipital view of the patient in Figure 6.2
CHAPTER 7
Senescent balding (senile alopecia)
Pure senescent alopecia is found in patients who boast a full head of hair well
into middle age, and who typically deny a family history of balding. Patients
with senescent alopecia note a very slow but steady, diffuse thinning of scalp
hair starting at age 50 and older. Women who complain of a marked degree of
thinning in the few years following menopause probably have a component of
androgenetic alopecia. Many (and perhaps most) patients with senescent alopecia
also have mild concomitant androgenetic alopecia, and the superimposed clinical
and histological features of common balding and senescent alopecia may be
impossible to separate.
Several authors have assessed the effect of aging on hair density by studying
the scalp surface (i.e., clinical rather than histological evaluation). The results of
these studies indicate that the density of hair follicles decreases steadily with
aging. There is little information available on the histological evaluation of scalp
biopsy specimens taken from normal individuals of various ages.
HISTOLOGICAL FINDINGS
The global impression when studying transverse sections is that there is only a
slight numerical reduction in follicles that are otherwise normal. Compared to
normal (or youthful) scalp, more follicles are in the telogen phase, but the
telogen count may still be within the range of normal. Inflammation is
uncommon, and fibrous streamers such as those found in androgenetic alopecia are
absent. The follicles are not as long or as wide as normal, but miniaturization
such as that seen in androgenetic alopecia is absent. All these subtle findings
would be uniform over the scalp surface.
The following combination of histological findings (based on 4-mm punch
biopsy specimens) is typical of senescent alopecia (Figures 7.1 and 7.2):
(1) A slight decrease in the total number of hairs (2035 as opposed to the normal
3045)
(2) Numbers of telogen hairs within the range of normal (less than 15%)
(3) A normal percentage of terminal hairs, with terminal hairs outnumbering
vellus and indeterminate hairs by at least 2:1
Figure 7.1 The crown in senescent alopecia. The specimen is from an elderly patient with
mild, diffuse thinning of hair who complained of gradual hair loss over a period of several
years. The two specimens (here and in Figure 7.2) closely resemble each other and are
within the range of normal for number, size and follicular phase of hairs. Original
magnification 40
Figure 7.2 The occiput in the same patient as in Figure 7.1. Original magnification 40
(4) An absence of deep, perifollicular inflammation

Given these findings, androgenetic alopecia can be excluded because of the
relative preponderance of terminal hairs, and the normal number of telogen
follicles excludes telogen effluvium. If crown/vertex and midoccipital biopsy
specimens from patients with senescent alopecia are compared, histological
findings will be similar at both sites. This contrasts with androgenetic alopecia,
where histological changes in the occiput (if present) are less dramatic than at the
vertex or crown.
67
SUMMARY
Clinical correlation: an elderly person who admits to very gradual thinning of
the hair; hair density appears normal (for age) or diffusely thinned over the entire
scalp.
Histological findings:
The specimen may appear entirely normal

Findings from the crown/vertex resemble those found on the occipital scalp
In advanced disease, the total number of hairs is reduced
Terminal: vellus hair ratio and telogen count remain normal
BIBLIOGRAPHY
Hordinsky M, Sawaya M, Roberts JL Hair loss and hirsutism in the elderly. Clin Geriatr
Med 2002; 18:12133
Kligman AM. The comparative histopathology of male-pattern baldness and senescent
baldness. Clin Dermatol 1988;6:10818
1995; 22:97114
CHAPTER 8
Androgenetic alopecia is also known as common balding, hereditary balding,

male-pattern balding and female-pattern balding. Some authors speculate that the
pathogenesis of balding differs between men and women. However, the
histopathological findings are similar in both sexes. Many women with a genetic
predisposition to baldness first notice the onset or an acceleration of shedding
and thinning around the time of menopause. However, some less fortunate
women, especially those with strong family histories for balding, begin to thin in
early adulthood. In the majority of cases, thinning is localized to the crown of the
scalp, with sparing of the occipital and lower parietal fringe of hair (Figures 8.1
and 8.2). Two patterns of hair loss can be seen: Hamiltons male pattern and
Ludwigs female pattern. In fact, there is considerable overlap between the
sexes, with many women demonstrating a male pattern of hair loss, and some
men showing a female pattern, with diffuse crown thinning and retention of the
frontal hairline.
In exceptional cases, the pattern of hair loss in both men and women with
androgenetic alopecia can be truly diffuse (authors personal observation), with
thinning of the occiput as well as the crown. In these cases, histological
confirmation may be required to establish the diagnosis with certainty.
Once considered a histological diagnosis of exclusion, androgenetic alopecia has
distinctive and diagnosable features. The diagnostic breakthrough has been the
study of transverse sections of scalp biopsies, a technique popularized through
the efforts of Headington and others. The microscopic diagnosis of androgenetic
alopecia depends more on quantitative than qualitative features. Therefore, the
ability to identify all follicles within a biopsy specimen is required to establish the
diagnosis. Ideally, 4-mm punch biopsy specimens should be taken from both the
involved and the relatively uninvolved sites (usually crown/vertex and occiput,
respectively). All specimens should be sectioned horizontally. Uninvolved skin
can serve as the patient s normal control. If the condition is advanced, a single
specimen from balding skin may be sufficient.
ANDROGENETIC ALOPECIA 69
Figure 8.1 Typical androgenetic alopecia in a young woman. Thinning is most prominent
over the crown
Androgenetic alopecia is characterized by progressive miniaturization of hair

follicles. This results in a mixture of hairs with various bulb depths and shaft
diameters. When one examines a specimen from a normal scalp, sectioned
transversely through the lower dermis, one gets the global impression that all
hairs are terminal hairs of similar size (diameter). A biopsy specimen from a
patient with androgenetic alopecia, sectioned at the same level, will show hairs
that appear vastly different in diameter (Figures 8.38.6). Below each
miniaturized follicle is a streamer, the collapsed connective tissue sheath that
once surrounded the formerly deep-seated, terminal hair. Streamers can also be
found beneath follicles that have become temporarily miniaturized, as in alopecia
areata. The streamers found in early androgenetic alopecia can be difficult (if
not impossible) to distinguish from the collapsed fibrous root sheath (follicular
stela) found below a normal terminal follicle that has temporarily entered the
catagen/telogen phases. After a streamer has been present for years (as in late
androgenetic alopecia), the streamer becomes less vascular and assumes a
grayish hue when stained with hematoxylin and eosin (Figures 8.78.9). The
Figure 8.2 The same patient as in Figure 8.1. There is relative sparing of the occiput
normal ratio of terminal: vellus hairs should be at least 2:1, but specimens
diagnostic of androgenetic alopecia show a reduction in this ratio. In advanced
cases, the number of vellus and indeterminate hairs will actually surpass the
number of terminal hairs (Figures 8.10 and 8.11). Early in the course of balding,
the total number of follicles present remains normal. Also, sebaceous glands
persist even when the hairs have greatly miniaturized (Figure 8.12). However, in
very long-standing balding, there is an actual decrease in follicular density as
well as follicular size. Therefore, androgenetic alopecia shows a biphasic pattern
of hair loss and may eventually resemble cicatricial alopecia.
As hairs miniaturize, the anagen phase becomes shorter. Therefore, the balding
scalp shows an increase in the telogen count, since miniaturized hairs spend a
greater proportion of each hair cycle in the telogen phase. In well-established
androgenetic alopecia, the majority of telogen follicles will be miniaturized
follicles (Figure 8.13). Successful treatment with minoxidil or finasteride will
increase the size of follicles and reduce the telogen count, presumably by
lengthening the duration of anagen.
Figure 8.3 Section (involved vertex) taken at the level of the dermal/fat junction. In this
woman with early androgenetic alopecia, the number of follicles in the vertex specimen is
similar to the number in the occipital specimen (Figure 8.4). However, follicles in the
vertex specimen show considerable variation in diameter, and many are quite small.
Inflammation has been described as a histological feature of androgenetic

alopecia, but balding should be regarded as a form of non-inflammatory hair loss.
Many biopsy specimens of androgenetic alopecia show mild, perifollicular,
lymphohistiocytic, upper dermal inflammation, sometimes associated with mild
perifollicular fibrosis. These changes are subtle and non-specific, and can also be
found in many normal scalp specimens. Mild, peri-infundibular chronic
inflammation is especially common in African American women and can be
regarded as normal. Peribulbar or destructive inflammation is absent in common
balding.
Figure 8.4 The same patient as in Figure 8.3, with this section taken from the normal
occiput. Original magnification 40
SUMMARY
Clinical correlation: symmetric thinning, predominantly affecting crown, vertex
and frontal regions, with relative sparing of the occiput; no evidence of scarring.
Family history of balding is usually elicited.
Histological findings (Figures 8.14 and 8.15):
Normal total number of follicles (about 35 in Caucasians or 20 in African

Americans per 4-mm plug)
Reduced number of hairs (mixture of terminal and indeterminate) when
counted at the dermal/fat junction
Increased numbers and percentage of vellus and indeterminate hairs when
counted at the level of the upper dermis
Presence of fibrous streamers below miniaturized hairs
Slightly increased telogen count compared with unaffected scalp
Uninvolved scalp (e.g., occiput) appears normal or relatively normal
Figure 8.5 Involved vertex. The same specimen as in Figure 8.3, but here sectioned at the
level of the mid- to upper dermis. The marked variation in hair size in the vertex specimen
is evident However, the total number of hairs in both vertex and occipital (Figure 8.6)
specimens appears normal. Original magnification 40
No significant inflammation
BIBLIOGRAPHY
Kligman AM. The comparative histopathology of male-pattern baldness and senescent
baldness. Clin Dermotol 1988; 6:10818
Lattanand A, Johnson WC. Male pattern alopecia: a histopathologic and histochemical
study. J Cutan Pathol 1975; 2: 5870
1995; 22:97114
Van Neste D, Fuh V, Sanchez-Pedreno P, et al. Finasteride increases anagen hair in men
with androgenetic alopecia. Br J Dermatol 2000; 143:80410
Whiting DA,Waldstreicher J,Sanchez M, Kaufman KD. Measuring reversal of hair
miniaturization in androgenetic alopecia by follicular counts in horizontal sections of
Figure 8.6 Normal occiput. The same specimen as in Figure 8.4, but here sectioned at the
level of the mid- to upper dermis. Original magnification 40
serial scalp biopsies: results of finasteride I mg treatment of men and
postmenopausal women. J Invest Dermatol Symp Proc 1999; 4:2824
specimens in male-pattern androgenetic alopecia. J Am Acad Dermatol 1993; 28:
75563
Figure 8.7 Follicular stelae (streamers) in a 50-year-old woman with androgenetic

alopecia. Old streamers, such as those seen here and in Figure 8.8, have a gray-blue hue
and few vascular spaces. Original magnification 400
Figure 8.8 Old streamer, in the same woman as in Figure 8.7. Original magnification
400
Figure 8.9 Relatively new stela, in a 16-year-old girl with androgenetic alopecia. Such
streamers, found in more recently miniaturized hairs, show more prominent vascularity.
Figure 8.10 Involved vertex. The same specimen as in Figure 8.3, sectioned at the level
of the mid- to upper dermis. When multiple follicular units from the balding scalp are
examined, most will show that vellus hairs equal or even outnumber terminal hairs.
Figure 8.11 Normal occiput. The same specimen as in Figure 8.5, sectioned at the level
of the mid- to upper dermis. Here, when multiple follicular units from the normal scalp
are examined, terminal hairs outnumber vellus hairs. Original magnification 200
Figure 8.12 A follicular unit in which all hair shafts have miniaturized. Even so, the
sebaceous glands remain intact. Original magnification 200
Figure 8.13 Involved crown of a woman with androgenetic alopecia. The percentage of
telogen hairs is increased, but the majority of telogen hairs are vellus or indeterminate
hairs. Original magnification 200
Figure 8.14 A 16-year-old girl with marked androgenetic alopecia. All the typical
histological features are present, including: normal number of follicles; variation in
follicular size; vellus and indeterminate follicles outnumbering terminal follicles;
increased percentage of catagen/telogen follicles; and no significant inflammation.
Figure 8.15 The same specimen as in Figure 8.14. Original magnification 200
CHAPTER 9
Telogen effluvium
A telogen effluvium occurs when abnormally large numbers of anagen hairs from
all areas of the scalp enter the telogen phase. This may be caused by some sort of
endogenous stress to the follicles, such as a metabolic disturbance, nutritional
deficiency, or serious systemic illness. Other cases of telogen effluvium are
physiological, and not indicative of disease. The many possible causes are
listed in Table 9.1. In response to the causative factor, many hairs prematurely
enter the catagen phase. This is a committed step for follicles; having entered
catagen they must proceed through the telogen phase and shedding before a new
anagen hair can regrow.
Telogen effluvium is probably the most common form of hair loss associated
with systemic diseases, especially chronic and debilitating conditions. However,
only the most dramatic cases of telogen effluvium, resulting in more than 25%
hair loss, are likely to come to clinical attention. Most drugs that have been
associated with hair loss, with the exception of anticancer medicines and other
toxins, cause hair loss by way of a telogen effluvium.
Physiological forms of telogen effluvium include postpartum and neonatal
hair loss. In postpartum telogen effluvium, numerous hair follicles are artificially
maintained in the anagen state under the influence of gestational hormones. This
is reflected in the lower telogen counts that occur towards the end of pregnancy.
After parturition, numerous follicles suddenly enter the catagen/telogen phase,
and shedding of hairs begins about 3 months later.
Telogen effluvium of the newborn represents the nearly universal shedding of
scalp hair during the first
Table 9.1 Causes of telogen effluvium
Physiological (not pathological)
Physiological effluvium of the newborn
Postpartum
Injury or stress (pathological)
Post-febrile (extremely high fevers, e.g. malaria)
Severe infection
Severe chronic illness
Severe, prolonged psychological stress
Post-surgical (implies major surgical procedure)

Hypothyroidism, hyperthyroidism and other endocrinopathies
Crash or liquid protein diets; starvation
Drugs
retinoids (e.g., acitretin, etretinate, isotretinoin)
anticoagulants (especially heparin)
antithyroid (e.g., propylthiouracil, methimazole)
anticonvulsants (e.g., phenytoin, valproic acid, carbamazepine)
heavy metals
-blockers (e.g., propranolol)
6 months of life. This may occur rapidly, resulting in obvious alopecia, or may
proceed slowly and imperceptibly. In either case, large numbers of anagen hairs
enter telogen within a period of months.
Many adult women suffer from a chronic telogen effluvium with no definable
precipitating event. This has been termed chronic telogen effluvium, and is a
diagnosis of exclusion. Many or most of these women have self-limited disease,
although the condition may last for several years before spontaneous resolution.
The early stage of androgenetic alopecia has features of a chronic, localized
form of telogen effluvium. The vertex and frontal hairs of the balding scalp
experience a marked reduction in the length of anagen. A much higher
proportion of hairs are thus entering telogen at any given time. Hair shedding is
only obvious during the early stages of the balding process, when large, terminal
hairs are being shed. Once hairs have miniaturized, the shedding of vellus
telogen hairs is not apparent.
Patients with acute forms of telogen effluvium notice hair loss about 3 or 4
months after the precipitating event. This corresponds to the time it takes for a
hair to move through catagen and the early stages of telogen. Scalp hair density
may appear normal, despite the patients complaint of profuse hair loss. If alopecia
is clinically obvious, the loss appears diffuse, affecting all parts of the scalp
(Figure 9.1). A gentle hair pull will yield several hairs with the depigmented,
cornified, clubbed morphology of telogen hair roots. A forcible hair pluck will
produce a mixture of normal anagen and telogen hairs, as well as an occasional
catagen hair (Figure 9.2). The percentage of telogen hairs will be increased to
more than 20%, a criterion without which the diagnosis of telogen effluvium
cannot be established with certainty. In the typical case of telogen effluvium, the
telogen count does not exceed 50%. However, exceptions to this rule have been
reported, and counts can reach 80%. Figures exceeding 80% are inconsistent
with a simple case of telogen effluvium.
Just as in androgenetic alopecia, the histological diagnosis of telogen effluvium
depends more on quantitative than qualitative features. The only abnormality in
a pure case of telogen effluvium is an increase in the percentage of terminal
TELOGEN EFFLUVIUM 83
Figure 9.1 This patient with newly diagnosed hypothyroidism demonstrates the typical
pattern of telogen effluviumthinning of hair over the entire scalp, including the
occipital and parietal regions
telogen follicles. Therefore, the total number of hairs in the specimen will be
normal, but there will appear to be a reduced number of terminal hairs when
counted at the dermal-fat junction. Fibrous streamers (stelae) replace the
missing terminal hairs at this level (Figures 9.3 and 9.4). These streamers lie
beneath the bulbs of the terminal telogen hairs, which are found in the middermis. Once counted, the telogen hairs are increased in number, and the telogen
count (number of terminal telogen hairs divided by the total number of terminal
hairs) will be greater than 20%. However, a lower number does not exclude the
diagnosis of telogen effluvium. If a patients normal telogen count happens to be
5%, a telogen count of 15% would be clearly abnormal for that patient.
Unfortunately, we do not know the baseline telogen counts for individuals, so
numbers less than 20% must be regarded as equivocal. Values of 1520% are
often found in cases of chronic, low-grade telogen effluvium. Even lower
numbers can be consistent with this diagnosis.
Figure 9.2 Portion of a forcible hair pluck (trichogram) obtained from the scalp of a
young woman with a telogen effluvium secondary to systemic lupus erythematosus. There
is a mixture of normal-appearing anagen and telogen bulbs, but the telogen bulbs are overrepresented. When all hairs were counted, the telogen count was 35%. Original
magnification 40
Figure 9.3 Telogen effluvium secondary to retinoid therapy. This specimen, sectioned at
the level of the dermal-fat junction, demonstrates a reduced number of terminal anagen
hairs. However, the terminal anagen hairs present are roughly similar in diameter. Several
catagen/telogen hairs are seen, as well as a few stelae (underlying additional catagen/
telogen hairs). After all follicles were counted, the total number was normal but the
percentage of telogen hairs was elevated at 40%. Original magnification 40
The size of hairs is not affected in a telogen effluvium. Abnormally large

numbers of terminal (large) anagen hairs are converted into terminal telogen
hairs, but miniaturization does not occur (Figure 9.5). Therefore, the terminal :
vellus hair ratio is normal (greater than 2:1).
In a simple case of telogen effluvium, both crown/vertex and occiput are
involved (truly diffuse hair loss). In fact, all body hair will be affected by the
disease, which may clinically be evident by thinned eyebrows, pubic hair and
axillary hair. If paired biopsy specimens (crown and occiput) are obtained, the
histological findings will be similar at both sites.
TELOGEN EFFLUVIUM 85
Figure 9.4 The same specimen as in Figure 9.3 (T, telogen follicle). Original
magnification 100
Figure 9.5 Telogen effluvium is characterized by an increase in the percentage of telogen

hairs without a decrease in the overall size of hairs.The two terminal telogen hairs in this
field have been sectioned through their secondary hair germs (SHG). Original
magnification 200
Telogen effluvium is a non-inflammatory form of hair loss, and no significant

inflammation is found. In particular, peribulbar inflammation and inflammation
affecting the lower two-thirds of the follicles is absent.
SUMMARY
Clinical correlation: history of a precipitating event (2 or 3 months prior to hair
loss) is often obtainable childbirth, major surgery or severe illness, certain
medications, etc.
Normal total number of follicles

Normal terminal: vellus hair ratio
Marked increase in percentage of terminal telogen hairs

Presence of fibrous streamers indicating conversion to telogen hairs
Normal size of follicles; no significant inflammation
BIBLIOGRAPHY
Guarrera M, Rebora A. Anagen hairs may fail to replace telogen hairs in early androgenic
female alopecia. Dermotology 1996; 192:2831
Headington JT. Telogen effluvium. New concepts and review. Arch Dermatol 1993; 129:
35663
Kligman AM. Pathologic dynamics of reversible hair loss in humans. I. Telogen
effluvium. Arch Dermatol 1961; 83:17598
Rebora A. Telogen effluvium: an etiopathogenetic theory. Int J Dermatol 1993; 32:
33940
Rebora A. Telogen effluvium. Dermotology 1997; 195:20912
Sperling LC, Lupton GP. The histopathology of non-scarring alopecia. J Cutan Pathol
1995; 22:97114
Sulzberger MB, Witten VH, Kopf AW. Diffuse alopecia in women. Arch Dermatol 1960;
81:55660
Whiting DA. Chronic telogen effluvium: increased scalp hair shedding in middle-aged
women. J Am Acad Dermatol 1996; 35:899906
CHAPTER 10
Trichotillomania
Trichotillomania is caused by the habitual, compulsive or intentional pulling and

plucking of hair. Although it can be found in persons who are mentally or
emotionally ill, many patients are healthy. However, with careful questioning, a
history of significant stress or turmoil at school, home or work can often be
obtained. Frequently, patients are school-aged children, and often both child and
parents deny the possibility of pulling or plucking as a cause of hair loss.
Therefore, a biopsy specimen can be crucial for establishing the diagnosis with
certainty.
Lesions of trichotillomania are often irregularly shaped, with bizarre or
geographic outlines. The bald patches are usually sharply demarcated from the
surrounding normal scalp, and typically there are several retained short hairs of
various lengths within the zone of alopecia (Figure 10.1). The scalp surface is
usually not inflamed, but occasionally excoriations from scratching or picking
may be present.
The most distinctive and diagnostic histological feature of trichotillomania is
incomplete, distorted follicular anatomy. In the process of plucking, some or all
of the follicular epithelium may be removed from the follicle, and the residual
tissue collapses to fill the void. Normally, the inner root sheath surrounds either a
hair shaft or the oval space occupied by the shaft before processing. A collapsed
inner root sheath indicates prior extraction of the hair shaft and is the most
common histological defect encountered in trichotillomania (Figures 10.2 and
10.3). When both the shaft and the inner root sheath are extracted, the outer root
sheath collapses upon itself. Infrequently, all or most of the epithelium is
removed, and the fibrous root sheath along with any retained epithelial fragments
and extravasated red blood cells form a vertical column.
Mechanical trauma to the hair frequently propels anagen follicles into the
catagen phase. Therefore, increased numbers of catagen and telogen hairs are
found in trichotillomania (Figure 10.4). Catagen hairs will be found in areas that
have recently been plucked, and telogen hairs are present a few weeks after the
traumatic event (Figures 10.5 and 10.6).
Figure 10.1 Typical lesion of trichotillomania.The site chosen for the biopsy samples is
evident
Figure 10.2 Incomplete and distorted follicular anatomy in trichotillomania. A terminal

anagen hair has lost its shaft from plucking. The inner root sheath has collapsed upon
itself. Original magnification 400
Frequently, chunks of pigmented hair matrix or cortex cells are torn from their
moorings during the plucking process, and come to rest in superficial portions of
the follicles (Figure 10.7). These cells then shrink to form a dark black
homogeneous clump called a pigment cast (Figure 10.8). Pigment casts are
simply the byproduct of fragmented, ectopic matrix or cortical epithelium.
If the hair matrix and suprabulbar epithelium is injured, but not severely
disrupted, the follicle may remain in the anagen phase, producing a hair shaft.
However, the shaft that is formed may be distorted in shape, smaller than normal
and incompletely cornified. This is termed trichomalacia (Figures 10.910.11).
Although trichomalacia is very characteristic of trichotillomania, it is not found
exclusively in this condition (refer to the section on alopecia areata, Chapter 14).
Pulling or plucking does not incite inflammation but may cause some
hemorrhage within the lower portion of the follicle (Figure 10.12). Even very
dramatic cases of trichotillomania are remarkably free of an inflammatory
TRICHOTILLOMANIA 89
Figure 10.3 A similar follicle (on the left) to that in Figure 10.2. On the right is a normal
follicle for comparison. Original magnification 200
Figure 10.4 Catagen hairs are frequently found in trichotillomania. Two catagen hairs are
present in this field. The follicle on the right is sectioned through the newly forming
club. Original magnification 400
infiltrate. Very rarely, a few eosinophils are found surrounding the lower portion
of a badly traumatized follicle.
SUMMARY
Clinical correlation: the patient is often a child or teenager, and a history of
emotional stress at home, school or work may be elicited. The involved areas are
irregularly shaped, sharply marginated patches with some retained short hairs of
various lengths.
Follicles are of normal size

Total number of hairs (both terminal and vellus) is normal
Incomplete, disrupted follicular anatomy is diagnostic, but not always present
Increased number of terminal catagen and/or telogen hairs (fibrous
streamers are also present if telogen hairs are increased in number)
Trichomalacia and pigment casts often found
Figure 10.5 Increased numbers of telogen hairs are seen in this specimen from a patient with
trichotillomania. Original magnification 400
Figure 10.6 Increased numbers of telogen hairs (or underlying stelae) are seen in this
specimen from a patient with trichotillomania. The histological differential diagnosis at
this level would include telogen effluvium. Original magnification 40
No significant inflammation (peribulbar inflammation absent)
TRICHOTILLOMANIA 91
Figure 10.7 A clump of non-cornified cortex cells has been stranded at an ectopic level
during the plucking process. Eventually, such cells shrink and cornify to form pigment
casts. Original magnification 400
Figure 10.8 A pigment cast within the center of a telogen follicle. Original magnification
400
BIBLIOGRAPHY
Bergfeld W, Mulinari-Brenner F, McCarron K, Embi C. The combined utilization of
clinical and histological findings in the diagnosis of trichotillomania. J Cutan Pothol
2002; 29:20714
Muller SA. Trichotillomania: a histopathologic study in sixty-six patients. J Am Acad
Dermotol 1990; 23:5662
Sperling LC, Lupton GR The histopathology of non-scarring alopecia. J Cutan Pothol
1995; 22:971 14
Walsh KH, McDougle CJ. Trichotillomania. Presentation, etiology, diagnosis and
therapy. Am J Clin Dermatol 200l; 2:32733
Whiting D. Dermatopathology of common hair problems. J Cutan Med Surg 1999; 3
(Suppl 3):S313
Figure 10.9 Trichomalacia. Two black pigment casts and two trichomalacic shafts can be
seen. Original magnification 400
Figure 10.10 Trichomalacia. A single trichomalacic shaft is found. Original magnification

400
TRICHOTILLOMANIA 93
Figure 10.11 Trichomalacia. Another example with a single trichomalacic shaft. Original
magnification 400
Figure 10.12 Extravasated red blood cells in the bulb of a catagen hair. Original
magnification 200
CHAPTER 11
Traction alopecia
Like trichotillomania, traction alopecia is a form of mechanical, traumatic

alopecia. However, trauma to the hair is usually mild and chronic. Although
vigorous scratching or combing may cause traction alopecia, most cases are
caused by hairstyles involving tight braiding or banding of the hair. The
condition is most common among African American girls whose hair-styles
involve nearly continual braiding. However, the identical pattern of hair loss can
be seen in persons of all races. Some girls get the condition after wearing tight
ponytail type hairstyles.
The hair loss tends to be a peripheral or marginal form of alopecia, i.e.,
involving the frontal, temporal and parietal margins of the scalp (Figure 11.1). In
girls who wear tight braids, perifollicular erythema and pustule formation may be
seen. Whether this inflammation is caused by traction or by cosmetics used in
conjunction with hair styling is unknown.
Traction alopecia is a biphasic form of hair loss. Initially the hair loss is
temporary, hair regrowth occurs and the condition behaves like a non-scarring
form of alopecia. However, if excessive traction is maintained for years, the hair
loss may eventually become permanent (end-stage or burnt out; Figure 11.2).
There may be a lag period of a decade or more between the period of traction and
the onset of permanent hair loss. Therefore, many African American women
present in their thirties and forties with a several-year history of persistent,
bitemporal or frontal hair loss. These women may deny having worn tight braids
since child-hood, although often other forms of traumatic styling (e.g. curlers)
have been employed.
The histological findings in acute, reversible traction alopecia and permanent,
long-standing, burnt out traction alopecia are entirely different. The acute form,
most commonly seen in African American girls or after a short-lived, traumatic
hairstyle (such as a hair weave or corn row), resembles a mild form of
trichotillomania. Occasionally, distorted or incomplete follicular anatomy is seen.
More often, there is an increase in catagen/telogen hairs, pigment casts and
subtle trichomalacia. Follicular numbers are normal.
TRACTION ALOPECIA 95
Figure 11.1 Thinning of hair around the margins of the scalp in a girl with a history of
tightly braided hair
Figure 11.2 Burnt out or end-stage traction alopecia in a 30-yeaf-old woman with
permanent hair loss, confirmed by biopsy
In end-stage disease, most commonly found in young African American

women, the total number of hairs is markedly reduced (Figures 11.3 and 11.4).
This is accounted for by the loss of terminal hairs, because vellus hairs are still
present in normal numbers (Figures 11.511.9). Sometimes the missing follicles
appear to have disappeared without a trace, because the dermal collagen appears
normal, but often some old stelae can be found when deeper levels are
examined (Figures 11.10 and 11.11). In many cases, distinct columns of
connective tissue replace some follicles, leaving obvious blank spaces
(Figure 11.12).
The sebaceous glands associated with the remaining hairs are still intact, and
often persist in follicular units that seem to have lost all their follicles. The
presence of sebaceous glands and relative normality of the dermal architecture,
despite marked hair loss, is highly characteristic of end-stage traction alopecia.
No significant perifollicular inflammation is present in either early or late
disease.
Figure 11.3 Mild traction alopecia in an adult woman. The number of terminal anagen
hairs is reduced in the alopecic zone (seen here) as compared with normal-appearing
perilesional skin (see Figure 11.4). Original magnification 40
Figure 11.4 Normal-appearing perilesional skin contrasts with the lesional specimen
shown in Figure 11.3. Original magnification 40
SUMMARY
Clinical correlation:
Early or acute diseasepatient is often an African American child whose hair

is tightly braided; there is alopecia of the scalp margin or around braids.
End stage diseasepatient is usually an African American woman with
symmetric thinning of the temples and/or frontal regions.
Early or acute disease

Normal size of follicles
Total number of hairs (both terminal and vellus) is normal
The most prominent finding is increased number of terminal catagen and/or
telogen hairs (fibrous streamers may be present if telogen hairs are increased
in number)
Trichomalacia and pigment casts occasionally found
Incomplete, disrupted follicular anatomy rarely found
Figure 11.5 Low-power view of a specimen from a woman with end-stage traction
alopecia. The reduction in the number of terminal hairs is striking, but sebaceous glands
are preserved. Original magnification 40
Figure I 1.6 Another low-power view of a specimen from a second woman with endstage traction alopecia. Original magnification 40
Figure 11.7 Low-power view of a specimen from a third woman with end-stage traction
alopecia. Original magnification 40

End-stage or burnt out disease (Figure 11.13)
Figure 11.8 Specimen from a woman with end-stage traction alopecia. Terminal hairs are
markedly reduced from normal, but normal numbers of vellus hairs persist. Original
magnification 100
Figure 11.9 Specimen from a different woman than in Figure 11.8, also showing endstage traction alopecia. Original magnification 100
Marked decrease in total number of follicles and terminal follicles, with

retention of vellus hairs
Dermal collagen appears relatively normal except for occasional fibrous tracts
at sites of former follicles
Many or most follicular units still have associated sebaceous glands
BIBLIOGRAPHY
Aaronson CM. Etiologic factors in traction alopecia. South Med J 1969; 62:1856
Earles RM. Surgical correction of traumatic alopecia marginalis or traction alopecia in
black women. J Dermatol Surg Oncol 1986; 12:7882
Hwang SM, Lee WS, Choi EH, Lee SH, Ahn SK. Nurses cap alopecia. Int J Dermatol
1999; 38:18791
Renna FS, Freedberg IM. Traction alopecia in nurses. Arch Dermatol 1973; 108:6945
Rudolph Rl, Klein AW, Decherd JW. Corn-row alopecia. Arch Dermatol 1973; 108:134
Scott DA. Disorders of the hair and scalp in blacks. Dermotol Clin 1988; 6:38795
Figure 11.10 Old stelae in a specimen from a patient with end-stage traction alopecia.
When sectioned transversely, these stelae appear as roughly oval condensations of
connective tissue containing a few small vascular spaces. Original magnification 200
Figure 11.11 Old stela in a specimen from another patient with end-stage traction
1995;22:97114
SteckWD. Telogen effluvium: a clinically useful concept, with traction alopecia as an
example. Cutis 1978; 21:5438
Trueb RM. Chignon alopecia: a distinctive type of nonmarginal traction alopecia. Cutis
1995; 55:1789
Figure 11.12 Columns of connective tissue marking the sites of former follicles are quite
obvious in this case of traction alopecia. In some cases, each column may represent the
former site of an entire follicular unit. Original magnification 100
Figure 11.13 Typical end-stage traction alopecia. Original magnification 200
CHAPTER 12
This form of hair loss is seen most commonly in patients who have undergone
lengthy surgical procedures, and had one portion of their scalp (usually the
occiput) in prolonged contact with the operating table. Postoperative alopecia can
occur at any age and is often associated with gynecological and open-heart
procedures requiring tracheal intubation. Less commonly, the condition is found
in patients who sustain blunt trauma to the scalp. Postoperative alopecia typically
presents as a solitary, roughly oval patch on the upper occiput (Figure 12.1).
Early in the course of the condition, erythema and induration are found in the
central portion of the lesion. Nearly total hair loss with fairly sharp demarcation
from the surrounding scalp is found just a few weeks after the initial trauma.
Usually complete hair regrowth occurs, although several cases of permanent (i.e.
cicatricial) hair loss have been reported.
The histological findings in postoperative alopecia change as the lesion evolves.
Early in the course of the disease, before hair loss is complete, vascular
thrombosis, inflammation and destruction may be seen in the dermis. Alopecia
develops up to 28 days following the surgical procedure. In the typical case of
postoperative alopecia, nearly all terminal follicles will be in the catagen or telogen
phases (Figures 12.2 and 12.3). This synchronized conversion of most or all
terminal hairs to the catagen/telogen phase is highly characteristic of
postoperative alopecia. Trichomalacia may be present, but not the distorted or
incomplete follicular anatomy sometimes found in trichotillomania
(Figure 12.4). Pigment casts are also commonly found (Figure 12.5). Melanin
pigment is usually found in the collapsed root sheaths below catagen/telogen
follicles.
Variable degrees of dermal fibrosis and chronic inflammation are present in
the papillary and upper reticular dermis. Focal vascular and tissue necrosis may
be present along with an associated chronic inflammatory infiltrate. Fat necrosis
is often found, associated with an infiltrate of foamy macrophages and
mononuclear cells (Figure 12.6). Inflammation is mild relative to the degree of
Figure 12.1 Postoperative alopecia. A large, nearly hairless, occipital patch was noted 3
weeks after a prolonged surgical procedure
Figure 12.2 Postoperative alopecia. Almost all follicles are in the catagen/telogen phase.
apparent tissue damage. The inflammation does not seem to be centered around
hair follicles, but is usually associated with foci of vascular and tissue necrosis.
SUMMARY
Clinical correlation: a patch of occipital hair loss occurring within a few weeks
of a prolonged surgical procedure requiring general anesthesia.
Almost all hairs in the catagen or telogen phase

Trichomalacia
Melanin pigment in collapsed fibrous root sheaths
Vascular thrombosis or necrosis with a relatively mild perivascular and
perifollicular inflammatory infiltrate
Fat necrosis with secondary infiltration by foamy macrophages and a few
lymphoid cells
POSTOPERATIVE (PRESSURE-INDUCED) ALOPECIA 103
Figure 12.3 Postoperative alopecia, as in Figure 12.2. Two catagen hairs can be seen.
Figure 12.4 Trichomalacia in postoperative alopecia. Original magnification 400
Figure 12.5 Pigment cast in a patient with postoperative alopecia. Original magnification
400
BIBLIOGRAPHY
Boyer JD,Vidmar DA. Postoperative alopecia: a case report and literature review. Cutis
1994; 54:32l-2
Hanly AJ,Jorda M, Badiavas E,Valencia I, Elgart GW Postoperative pressure-induced
alopecia: report of a case and discussion of the role of apoptosis in non-scarring
alopecia. J Cutan Pathol 1999; 26:35761
Figure 12.6 Fat necrosis with reactive granulomatous inflammation in a patient with
postoperative alopecia. Original magnification 400
Patel KD, Henschel EO. Postoperative alopecia. Anesth Analg 1980; 59:31113
Sperling LC, Lupton GP The histopathology of non-scarring alopecia. J Cutan Pathol
1995; 22:97114
Wiles JC, Hansen RC. Postoperative (pressure) alopecia. J Am Acad Dermatol 1985; 12:
1958
CHAPTER 13
Also known as congenital triangular alopecia, temporal triangular alopecia may

be present at birth or acquired during the first decade of life. Lesions outside the
temporal area, and those acquired in adulthood, can rarely occur. The lancetshaped lesions (Figure 13.1) are a few centimeters in width, may be unilateral or
bilateral, and are oriented so that that the tip of the lancet points superiorly and
posteriorly. Lesions appear hairless, but very fine vellus hairs can be seen with
magnification. Once present, the patches of alopecia persist for life.
Microscopically, there are normal numbers of follicles, but almost all are
vellus hairs. The small size of the hairs necessitates transverse sectioning for
adequate assessment (Figures 13.213.6). All other features of the epidermis,
dermis and other adnexae are entirely normal, and inflammation is absent. The
condition appears to be a process of follicular miniaturization confined to a
small, lancet-shaped area of the temporal region, resulting in the characteristic
bald spot. However, fibrous streamers (stelae) as found in androgenetic
alopecia are not found in temporal triangular alopecia (Figure 13.7). Congenital
cases presumably undergo the process of follicular miniaturization in utero (or
terminal hair formation never occurs).
SUMMARY
Clinical correlation: lancet-shaped bald spot (may be bilateral) discovered on the
temporal region of a newborn or young child; the remainder of the scalp is
normal.
Normal total number of hairs

Few, if any, terminal hairs
Almost all hairs are vellus hairs
No fibrous streamers (stelae)
No significant inflammation or other epidermal or dermal abnormality
Figure 13.1 Temporal triangular alopecia. This unilateral lesion was first noted when the
patient was 3 years old. The condition may also be congenital and/or bilateral
Figure 13.2 Temporal triangular alopecia. A section through the deep dermis reveals very
few follicles. Original magnification 40
BIBLIOGRAPHY
Armstrong DK, Burrows D. Congenital triangular alopecia. Pediatr Dermatol 1996; 13:
3946
Bargman H. Congenital temporal triangular alopecia. Can Med Assoc J 1984; 15:12534
Bargman H. Congenital triangular alopecia. J Am Acad Dermatol 1988; 18:390
TEMPORAL TRIANGULAR ALOPECIA 107
Figure 13.3 A section through the upper dermis (compare with Figure 13.2) in temporal
triangular alopecia demonstrates a normal number of follicles, almost all of which are
very small. Original magnification 40
Figure 13.4 A vertical specimen from a patient with temporal triangular alopecia reveals
a few vellus follicles. It is impossible to quantify the total number and average size of
follicles using vertical sections. Original magnification 100
Feuerman EJ. Congenital temporal triangular alopecia. Cutis 1981; 28:1967
Garcia-Hernandez MJ, Rodriguez-Pichardo A, Camacho F. Congenital triangular alopecia
(Brauer nevus). Pediatr Dermatol 1995; 12:3013
Kenner JR,Sperling LC. Pathological case of the month. Temporal triangular alopecia and
aplasia cutis congenita. Arch Pediatr AdolescMed 1998; 152:12412
Kim HJ, Park KB,Yang JM, Park SH, Lee ES. Congenital triangular alopecia in
phakomatosis pigmentovascularis: report of 3 cases. Acta Derm Venereol 2000;80:
21516
Kubba R, Rook A. Congenital triangular alopecia. Br J Dermatol 1976; 95:6579
Ruggieri M, Rizzo R, Pavone P, Baieli S, Sorge G, Happle R. Temporal triangular
alopecia in association with mental retardation and epilepsy in a mother and
daughter. Arch Dermatol 2000; 136:4267
Sperling LC, Lupton GP The histopathology of non-scarring alopecia. J Cutan Pothol
1995;22:97114
Tosti A. Congenital triangular alopecia. Report of fourteen cases. J Am Acad Dermatol
1987; 16:991 -3
Trakimas CA, Sperling LC. Temporal triangular alopecia acquired in adulthood. J Am
Acad Dermatol 1999; 40:8424
Figure 13.5 The small size of hairs in lesional skin from a patient with temporal
triangular alopecia is easily appreciated when compared to hair diameters in normal,
perilesional scalp (see Figure 13.6). Original magnification 100
Figure 13.6 A specimen showing normal, perilesional scalp in a patient with temporal
triangular alopecia. Original magnification 100
Figure 13.7 Temporal triangular alopecia. The dermis below the miniaturized follicles
appears normal, and stelae are not seen. Original magnification 100
Trakimas C, Sperling LC, Skelton HG 3rd, Smith KJ, Buker JL Clinical and histologic
findings in temporal triangular alopecia. J Am Acad Dermatol 1994; 31:2059
CHAPTER 14
Alopecia areata
Alopecia areata is a very common form of non-scarring hair loss, affecting 1% or

more of the population. The disease can affect any part of the body
(Figure 14.1), but scalp hair loss is the usual complaint. Severity ranges from a
small, circumscribed bald spot to total scalp hair loss (alopecia totalis), and even
total body hair loss (alopecia universalis). Both the clinical course and
histopathological features of relatively mild disease may differ significantly from
severe disease (alopecia totalis or universalis).
Several patterns of partial hair loss can be found, including circumscribed
(isolated oval patches; Figures 14.2 and 14.3), reticular (innumerable small
patches), ophiasis (marginal) and diffuse. In the very unusual diffuse form, hair
loss occurs over much of or the entire scalp, but circumscribed bald spots do not
form. However, hair loss is seldom so uniform or symmetrical that it cannot be
distinguished from a telogen effluvium. If the hair steadily and rapidly thins, the
diagnosis of alopecia totalis in evolution is more appropriate than that of diffuse
alopecia areata (Figure 14.4). Even in alopecia totalis or universalis, isolated
hairs or tufts of hairs may continue to grow.
The involved scalp is usually normal in color but may show slight erythema or
edema. Short hairs that taper as they approach the scalp are called exclamation
mark hairs, and if present are very characteristic of alopecia areata. Because of
shaft narrowing and hypopigmentation near the scalp surface, exclamation mark
hairs appear to float on the scalp surface (Figures 14.5 and 14.6). When hairs
are gently pulled from the edges of an expanding lesion of alopecia areata, many
telogen hairs and/or tapered pencil point shafts can be easily extracted
(Figure 14.7). Alopecia areata seems to affect pigmented hairs preferentially, and
hair regrowth may occur with depigmented hairs (Figure 14.8).
Very recent or rapidly progressive hair loss presents a very different histological
picture from long-standing, well-established disease. For the purpose of this
text, the pathology of alopecia areata will be divided into three stages, a concept
that is accepted by other authorities such as David A.Whiting. These stages,
which will be called acute, subacute and chronic, reflect the evolution of the
Figure 14.1 Alopecia areata affecting the beard area. This patient had no scalp hair loss
Figure 14.2 Typical circumscribed lesion of alopecia areata
Figure 14.3 Circumscribed lesion of alopecia areata
disease with the passage of time. Different stages of disease may be present at
the same time at different sites on the same scalp. In any given patient, separate
lesions of alopecia areata may begin, evolve, remit and recur independently of
one another.
The acute stage is seen in rapidly progressive disease or disease of recent onset,
as is found in evolving alopecia totalis or at the advancing margin of an
enlarging bald spot. The total number of follicles appears normal. Several
affected hairs are still terminal anagen follicles, with bulbs in the fat or deep
ALOPECIA AREATA 111
Figure 14.4 Alopecia totalis in evolution. This patient had rapid, diffuse hair loss
progressing over a period of just a few months
Figure 14.5 Patch of alopecia areata with several exclamation mark hairs
dermis. However, several follicles have entered the catagen/telogen phase

(Figures 14.914.12). Some (but seldom all) anagen phase and early catagen
phase hairs demonstrate a peribulbar mononuclear cell inflammatory infiltrate.
Both CD4+ and CD8+ T cells are found, but the relative proportion of these cells
has not yet been carefully correlated with the histological stage (Figure 14.13).
However, CD8+ cells are more likely to invade the epithelium (exocytosis) than
Figure 14.6 Exclamation mark hair. This hair was easily pulled from the scalp. The
wider, distal end (right side) shows a fracture, and the proximal end is narrow and
hypopigmented. Most exclamation mark hairs are in the telogen phase
Figure 14.7 Tapered,pencil point hair gently extracted from a patient with rapidly
progressive alopecia areata
CD4+ cells. In some cases, peribulbar inflammation may be subtle or even

absent, and other histological features are required to establish the diagnosis. The
presence of peribulbar inflammation is helpful but not essential to making the
diagnosis of alopecia areata.
Small numbers of eosinophils may be present, but plasma cells are unusual
(Figures 14.14 and 14.15). The infiltrate may invade the dermal papilla and hair
matrix, resulting in damage to matrix cells. Especially when exocytosis of
inflammatory cells into the hair matrix occurs, but sometimes in its absence as
well, the matrix appears blurred and somewhat disorganized (Figures 14.16 and
14.17).
There may be both intercellular (spongiosis) and intracellular edema. This
change may be subtle or quite prominent, and can affect the suprabulbar as well
as the bulbar zone (Figures 14.18 and 14.19). Some anagen follicles show
vacuole formation or necrosis of matrix cells located just above the upper pole of
the dermal papilla, corresponding to the site of early hair cortex formation
(Figure 14.20). This can result in small cystic spaces filled with acantholytic,
necrotic cells. Focal matrix cell vacuolization and necrosis is a characteristic
feature of alopecia areata, but it affects relatively few follicles and is found in
ALOPECIA AREATA 113
Figure 14.8 Alopecia totalis in evolution, with early sparing of hypopigmented hairs. This
patient had black, but graying hair until his hair loss began. The gray hairs were initially
spared, but eventually they too were shed
Figure 14.9 Acute alopecia areata. The number and size of hairs appears normal, but
there is an increase in the number of catagen/telogen hairs. Original magnification 40
only a minority of cases. Nuclear pyknosis and cell death (apoptosis) occurs not
only in matrix keratinocytes, but also in outer root sheath cells and bulbar
melanocytes. Amorphous clumps of pigment (pigment casts) are occasionally
found within the follicular epithelium as a byproduct of hair matrix degeneration
(Figure 14.21).
Figure 14.10 Acute alopecia areata, higher power image of section shown in
Figure 14.9. Original magnification 100
Figure 14.11 Acute alopecia areata. At this level,the number and size of hairs appears
roughly normal, but the presence of several slightly inflamed stelae (arrows) gives a clue
to the diagnosis. Original magnification 40
As a result of damaged bulbar melanocytes and keratinocytes, pigment

incontinence is often seen in the dermal papilla and follicular sheath of affected
hairs.
The second or subacute stage of alopecia areata does not correlate well with
the extent or duration of clinical disease. This stage is the one most commonly
encountered by pathologists. When all follicles are counted, requiring
examination of transverse sections at both deep and superficial levels, the total
number of follicles appears normal. However, in virtually all cases, there is a
marked increase in the percentage of catagen/telogen hairs, often exceeding 50%
of total follicles. Some of the catagen/telogen hairs are still terminal (large)
hairs, and a few deeply seated, terminal anagen hairs may also be seen.
Peribulbar inflammation tends to subside after the hair has entered the catagen
phase, so that late catagen and telogen hairs are usually free of inflammation
(Figure 14.22). However, a few inflammatory cells may persist near the lower
portion of some catagen/ telogen follicles, as well as within the collapsed sheaths
(Figures 14.2314.25).
Despite the peribulbar inflammation and matrix injury, some anagen hairs
continue to produce hair shafts. Some of these shafts show trichomalacia, and are
ALOPECIA AREATA 115
Figure 14.12 Acute alopecia areata, with several slightly inflamed stelae. Original
magnification 200
Figure 14.13 CD3+T cells (all T lymphocytes stain brown) surround and invade the
epithelium of an anagen hair. Varying proportions of CD4+ and CD8+T cells may be
present in such an infiltrate. Original magnification 400
Figure 14.14 Eosinophils join the lymphocytic infiltrate surrounding the bulb of this
catagen hair. Original magnification 400
smaller, incompletely cornified and distorted in shape. Many follicles produce

shafts that become progressively smaller in volume and cross-sectional
dimension. These hairs gradually taper down to a point (Figure 14.26), resulting
in an extremely fragile constriction. They represent the pencil point hairs which
fall from the scalp in great numbers. A transverse section through the site of
constriction may show a minute or absent (Figure 14.27) hair shaft. The term
Figure 14.15 Eosinophils join the lymphocytic infiltrate surrounding the bulb of this anagen
Figure 14.16 The hair matrix of this inflamed bulb appears blurred and disorganized.
Figure 14.17 Despite the scanty peribulbar infiltrate, the hair matrix appears blurred and
somewhat disorganized. Original magnification 400
anagen arrest (or anagen effluvium) has been applied to those forms of alopecia
characterized by the rapid tapering and shedding of large numbers of anagen
hairs. Anagen arrest is characteristic of chemotherapy-induced alopecia, but the
initial stages of alopecia areata (when terminal hairs are still present) also have
features of an anagen arrest.
ALOPECIA AREATA 117
Figure 14.18 Suprabulbar zone. The outer root sheath of this inflamed follicle (see also
Figure 14.19) appears blurred and somewhat disorganized. Some lymphocytes have
invaded the outer root sheath. Original magnification 400
Figure 14.19 Another example at the suprabulbar zone. Original magnification 400
Figure 14.20 A group of necrotic matrix cells lies just above the upper pole of the hair
papilla. Original magnification 400
However, after producing a dystrophic (or no) shaft for a period of time, these
anagen hairs eventually enter the catagen/telogen phase.
After remaining in the telogen phase for a period of time (about 100 days in a
normal follicle; an unknown length of time in alopecia areata), hair follicles reenter the anagen phase. Unless the disease has spontaneously subsided, an
Figure 14.21 Clumps of pigment are seen within the epithelium of this catagen hair.
inflammatory infiltrate again confronts the newly forming anagen hairs. This
results in a repetition of the pathological process: peribulbar inflammation,
disturbance of anagen hair growth and precipitation into the catagen/telogen
phase. As this process repeats itself over and over, the duration of anagen
becomes briefer, the anagen hairs miniaturize, and an increasingly large
percentage of hairs will be found in the catagen/telogen phase, sometimes
approaching 100% of the total (Figure 14.28).
The third histological stage, which here is referred to as chronic, is found in
stable, long-standing bald patches and in well-established alopecia totalis or
universalis. Terminal anagen hairs, with or without surrounding mononuclear
infiltrate, are rare. Thus, the most familiar histological finding of alopecia areata
may be absent. In addition, all the follicles may become miniaturized, but the
total number of follicles remains normal (Figures 14.29 and 14.30). This remains
true for years or even decades, but eventually follicular dropout may occur (an
example of the biphasic pattern of permanent alopecia; see Figure 4.1). When
follicles are miniaturized, they are often missed on routine vertical sectioning.
Transverse sections are required to examine and count all follicles.
The miniaturized anagen follicles found in chronic disease are situated in the
mid- to lower dermis, usually slightly deeper than normal vellus hairs
ALOPECIA AREATA 119
Figure 14.22 Inflammation predominantly surrounds the bulbs of anagen hairs (e.g. the
follicle at lower right). Late catagen/telogen follicles (e.g. upper left) are relatively
spared. Original magnification 200
Figure 14.23 Residual inflammation surrounds the bulb of an early catagen hair. Original
magnification 400
(Figure 14.31). Normally, anagen hairs develop through a series of

developmental stages named anagen I-VI. The majority of the miniaturized,
diseased follicles in alopecia areata develop to a stage resembling anagen III or
IV, but no further. These small, abnormal follicles have been called nanogen
hairs (nanos, Greek for dwarf), and are a distinctive feature of long-standing
alopecia areata. Nanogen hairs are not merely small. Their rapid and distorted
life cycle makes them difficult to categorize as anagen, catagen or telogen hairs.
The reasons for this are given below.
Nanogen hairs have an epithelial matrix that is small relative to the size of the
dermal papilla, which is also reduced in volume. The nuclei of the papilla
become rounder and the cells more compact, much as they do in the catagen/
telogen phase (Figure 14.32). Nanogen hairs can be identified in transverse
section because they have thin inner and outer root sheaths (two or three cell
layers), but no central hair shaft, or at most an extremely fine, incompletely
cornified shaft (Figures 14.3314.37).
Furthermore, they may simultaneously demonstrate morphological features of
both anagen and catagen/ telogen phases. The bulb may resemble that of an
anagen hair (basophilic cells with mitotic activity) while the suprabulbar portion
Figure 14.24 Residual inflammation surrounds the suprabulbar zone of an early catagen
Figure 14.25 The stelae below catagen/telogen hairs may also show residual
shows features of a catagen hair. Conversely, the bulb may show features typical
of a catagen hair while the suprabulbar zone possesses an anagen-like inner root
sheath with trichohyaline granules (Figures 14.3814.41). Nanogen hairs with
anagenlike bulbs may have some matrix cells in mitosis while others are
undergoing apoptosis (Figures 14.42 and 14.43). Thus, features of active growth
(mitotic cells) and involution (apoptotic cells) are seen simultaneously. The
ALOPECIA AREATA 121
Figure 14.26 This terminal anagen hair is still producing a hair shaft, but it is only a few
cells in width. Once the inner root sheath has desquamated, the shaft easily fractures at
this constriction to form a pencil point hair. Original magnification 400
strange histological characteristics of nanogen hairs signify a profound disorder

of cell cycling that is peculiar to alopecia areata. In most cases, the majority of
nanogen hairs will be found in the catagen/telogen phase (Figures 14.4414.48),
so that anagen-like nanogen hairs may be difficult to find. Nanogen hair bulbs
may be surrounded and sometimes invaded by inflammatory cells, but generally
the degree of inflammation is mild and often subtle. The most inflamed nanogen
bulbs are those with anagen-like and early catagen-like bulbs (Figures 14.49
14.51). Even in the chronic stage of alopecia areata there can be a surprising
amount of perifollicular inflammation and infiltration of hair follicles by
mononuclear cells. However, as in the acute stage, the telogen follicles are
relatively spared from an inflammatory infiltrate. In the chronic phase, the
majority (or all) of the follicles in a specimen may be in the catagen/telogen
phase, and so inflammation might be entirely absent (Figure 14.52). This results
in a picture of non-inflammatory alopecia areata, a surprising finding in
patients who may have very severe and dramatic clinical disease.
Below each miniaturized follicle is a collapsed fibrous root sheath (stela)
(Figure 14.53). It may contain numerous capillaries, a few inflammatory cells
and clumps of melanin, but these findings are less common than in the fibrous
sheaths of terminal hairs found in acute disease. Unless they are inflamed, these
collapsed sheaths appear identical to the fibrous streamers described in
androgenetic alopecia and telogen effluvium. Atrophy of sebaceous glands is
seldom seen in alopecia areata.
SUMMARY
Clinical correlation: patchy or circumscribed hair loss without evidence of
inflammation; may result in total scalp or body alopecia; lesions appear suddenly
and may expand rapidly; exclamation mark hairs may sometimes be seen.
Figure 14.27 This anagen hair has produced a cornified inner root sheath, but no cortex/
shaft formation has occurred. Original magnification 1000
Figure 14.28 The percentage of telogen hairs in subacute disease can approach 100%. The
remaining anagen hairs have begun to miniaturize. Original magnification 100
Early, severe or progressive disease (acute and subacute)

Normal total number of hairs
Peribulbar, mononuclear cell infiltrate (with occasional eosinophils),
predominantly affecting terminal anagen and catagen hair bulbs
ALOPECIA AREATA 123
Figure 14.29 Alopecia areata,chronic stage. The majority of the follicles are in the
telogen phase. Only a few terminal anagen hairs are present, and peribulbar inflammation
may be difficult or impossible to identify. Original magnification 40
Figure 14.30 Alopecia areata, chronic stage. See Figure 14.29. Original
magnification100
Occasional exocytosis of inflammatory cells into bulbar epithelium

Degenerative changes (nuclear pyknosis, inter- and intracellular edema,
vacuole formation) of hair matrix, especially the lower, central matrix
Increased number of terminal catagen and telogen hairs
Increased number of miniaturized hairs
Trichomalacia and marked narrowing of hair shafts
Figure 14.31 The bulb of this miniaturized anagen hair is located in the mid-dermis.
Figure 14.32 Nanogen hair. The bulbar epithelium of this inflamed hair is only a few
cells in thickness,and is thin relative to the diameter of the papilla. Original magnification
400
Long-standing and stable disease (chronic)

Majority of hairs in catagen or telogen phases
Numerous miniaturized, arrested, rapidly cycling hairs (nanogen hairs)
ALOPECIA AREATA 125
Figure 14.33 Nanogen hair. This transverse section at the level of the bulb shows the
features of a typical anagen-like nanogen hair. The matrix is thin and small relative to
the papilla. Original magnification 1000
Mild, peribulbar, mononuclear cell infiltrate around those nanogen hairs

having anagen-like or catagenlike bulbs
BIBLIOGRAPHY
El Darouti M, Marzouk SA, Sharawi E. Eosinophils in fibrous tracts and near hair bulbs: a
helpful diagnostic feature of alopecia areata. J Am Acad Dermatol 2000; 42:3057
Elston DM, McCollough ML, Bergfeld WF, Liranzo MO, Heibel M. Eosinophils in
fibrous tracts and near hair bulbs: a helpful diagnostic feature of alopecia areata. J
Am Acad Dermatol 1997; 37:1016
Freyschmidt-Paul P, Hamm H, Happle R, Hoffmann R. Pronounced perifollicular
lymphocytic infiltrates in alopecia areata are associated with poor treatment response
to diphencyprone. Eur J Dermatol 1999; 9:11114
Ghersetich I, Campanile G, Lotti T. Alopecia areata: immunohistochemistry and
ultrastructure of infiltrate and identification of adhesion molecule receptors. Int J
Dermatol 1996; 35:2833.
Figure 14.34 Nanogen hair. Transverse section at the level of the suprabulbar zone. There
is no central shaft formation. Original magnification 1000
Kim lH, Jo HY, Cho CG, Choi HC, Oh CH. Quantitative image analysis of hair follicles
in alopecia areata. Acta Dermatol Venereol 1999; 79:21416
Nutbrown M, MacDonald Hull SP, Baker TG, Cunliffe WJ, Randall VA. Ultrastructural
abnormalities in the dermal papillae of both lesional and clinically normal follicles
from alopecia areata scalps. Br J Dermatol 1996; 135:20410
Tobin SJ. Morphological analysis of hair follicles in alopecia areata. Microsc Res Tech
1997; 38:44351
Whiting DA. Histopathology of alopecia areata in horizontal sections of scalp biopsies. J
Invest Dermatol 1995; 104 (5 Suppl):26S-27S
Whiting DA. The histopathology of alopecia areata: a new look. Poster presentation at the
4th International Research Workshop on Alopecia Areata, November 2002.
Washington DC,2003; in press
ALOPECIA AREATA 127
Figure 14.35 Nanogen hair. Transverse section at a higher level of the suprabulbar zone.
The inner root sheath has cornified, but there is no shaft. (Same follicle as shown in
Figures 14.33 and 14.34.) Original magnification 1000
Figure 14.36 A vertically sectioned anagen-like nanogen hair corresponds to the type of
hair shown in Figures 14.3314.35. The extremely small size of such a hair is best
appreciated by comparing it to the bulb of a normal anagen hair (Figure 14.37),
photographed at the same magnification. Original magnification 400
Figure 14.37 Normal anagen hair. Original magnification 400
Figure 14.38 This transversely sectioned nanogen hair has the bulb of a catagen hair.
Figure 14.39 Catagen-like suprabulbar zone of the same nanogen hair shown in
ALOPECIA AREATA 129
Figure 14.40 More superficial level of the same nanogen hair seen in Figures 14.38 and
14.39, but here showing the anagen-like features of inner root sheath and cortex
formation. Original magnification 400
Figure 14.41 More superficial level of the nanogen hair shown in Figure 14.40. Original
magnification 400
Figure 14.42 This greatly magnified anagen-like nanogen hair has a matrix that is less
basophilic than normal, yet it produces inner root sheaths (found on more superficial
sections). In addition, both mitotic and apoptotic cells are found. Original magnification
1000
ALOPECIA AREATA 131
Figure 14.43 Another anagen-like nanogen hair bulb, as in Figure 14.42. Original
magnification 1000
Figure 14.44 A catagen-like nanogen hair adjacent to a terminal anagen hair. Note
the dramatic difference in size, and the more superficial location of the nanogen hair.
ALOPECIA AREATA 133
Figure 14.45 Another vertically sectioned catagen-like nanogen hair. Original

magnification 200
Figure 14.46 A follicle similar to those in Figures 14.44 and 14.45, sectioned transversely
through the bulb. Original magnification 400
Figure 14.47 Another transversely-sectioned catagen-like nanogen hair, showing the

suprabulbar area. Original magnification 400
ALOPECIA AREATA 135
Figure 14.48 Another transversely-sectioned catagen-like nanogen hair, sectioned

through the upper follicle. The central zone of cornification represents residual inner root
sheath formation. Original magnification 400
Figure 14.49 An unusually dense lymphocytic infiltrate surrounds the bulb of an anagenlike nanogen hair. Original magnification 400
Figure 14.50 An unusually dense lymphocytic infiltrate surrounds the bulb of a catagenlike nanogen hair. Original magnification 400
ALOPECIA AREATA 137
Figure 14.51 Immunoperoxidase stain for CD3+T cells high-lights the lymphocytes
surrounding the bulb of a nanogen hair. This stain may be helpful in cases where
inflammation is scanty. Original magnification 200
Figure 14.52 In this specimen demonstrating the chronic histological phase of alopecia
areata, the majority of the miniaturized follicles are in the telogen phase, and their bulbs
are not inflamed. Original magnification100
Figure 14.53 Three transversely sectioned stelae (streamers) in a patient with longstanding alopecia totalis. Original magnification 200
CHAPTER 15
Syphilitic alopecia
Syphilis, the great imitator, is capable of causing alopecia with several clinical
and histological patterns. Alopecia found in secondary syphilis may be
associated with other cutaneous lesions, or may be the only external
manifestation of syphilis. The pattern of hair loss can be patchy (moth-eaten),
diffuse or a combination of the two (Figure 15.1).
When papulosquamous lesions of secondary syphilis are found on the scalp in
association with alopecia (symptomatic syphilitic alopecia), the histological
findings are usually those typically associated with lesions of secondary syphilis.
These findings include: a perivascular and perifollicular infiltrate of
lymphocytes, histiocytes and often numerous plasma cells; involvement of both
superficial and deep dermal vascular plexuses; vascular dilatation and
prominent, swollen endothelial cells; and frequent epidermal involvement with
epidermal hyperplasia, spongiosis, infiltration with neutrophils and interface
inflammation.
Hair loss in the absence of papulosquamous lesions of the scalp is termed
essential syphilitic alopecia. The clinical pattern of hair loss may be motheaten or diffuse (as in telogen effluvium). Syphilis is one cause of telogen
effluvium, and in some cases of diffuse syphilitic alopecia the histological
pattern is that of a typical telogen effluvium (described in Chapter 9). However,
more often the pattern is an inflammatory, predominantly peribulbar and
suprabulbar, non-scarring process closely mimicking alopecia areata
(Figures 15.215.6). Catagen/telogen follicles are increased in number, initially
as terminal hairs, but eventually as miniaturized follicles. A mononuclear cell
infiltrate surrounds the inferior segment of the follicle or involves the fibrous
tracts below catagen/telogen hairs (Figure 15.5). A minority of specimens will
show a solitary peribulbar lymphoid aggregate, and in some cases large numbers
of lymphocytes infiltrate the outer root sheath at the isthmus level (Figure 15.6).
In well-established syphilitic alopecia, the majority or all the follicles have
miniaturized (Figures 15.7 and 15.8). The peribulbar infiltrate tends to be rather
scanty, and plasma cells may be difficult to find. Because so many follicles have
miniaturized, finding and counting involved hairs is best achieved with
transverse sectioning. Special stains for spirochetes do not reveal organisms.
Figure 15.1 Syphilitic alopecia that is both diffuse (affecting the entire scalp) and patchy
(affecting some areas more than others). This pattern is typical. Photograph courtesy of
Timothy Berger, MD
Eosinophils in the infiltrate are unusual, but in many cases plasma cells are
present in small numbers.
Syphilitic alopecia and alopecia areata may have the following features in
common:
(1) Sparing of the epidermis
(2) Infiltration of lymphocytes around the lower segment of follicles, in fibrous
tracts, or within the follicular epithelium
(3) Presence of small or abnormal anagen hairs
(4) Markedly increased numbers of catagen/telogen follicles
The presence of plasma cells and lymphocytic infiltration of the outer root sheath
is more likely to be seen in syphilitic alopecia than in alopecia areata.
Serological tests for syphilis and a prompt and complete response to
antitreponemal antibiotics help to confirm the diagnosis.
SUMMARY
Clinical correlation: a diffuse (resembling telogen effluvium) or a diffuse but
moth-eaten alopecia. Other signs and symptoms of syphilis may be present.
Symptomatic alopecia (associated with papulosquamous lesions)

Histological findings similar to typical papulosquamous lesions of secondary
syphilis
Superficial and deep perivascular and perifollicular infiltrate composed of
plasma cells, lymphocytes and histiocytes
Vascular dilatation and endothelial cell prominence
SYPHILITIC ALOPECIA 141
Figure 15.2 Early syphilitic alopecia showing an increased number of catagen hairs.
Original magnification 40. Slide courtesy of James W.Patterson, MD
Diffuse alopecia secondary to telogen effluvium

Identical to telogen effluvium as discussed earlier
Essential alopecia, moth-eaten or diffuse, inflammatory
Histological findings associated with typical lesions of secondary syphilis are
absent
Resembles alopecia areata: peribulbar mononuclear cell infiltrate,
miniaturization of hairs, increased number of catagen/telogen hairs
(approaching 100% in some cases)
Occasional plasma cells may help differentiate from alopecia areata
Perifollicular and outer root sheath inflammation may extend up to the
follicular isthmus
Positive serological test for syphilis and favorable response to antibiotics
Figure 15.3 Early syphilitic alopecia. Original magnification 100. Slide courtesy
of James W.Patterson, MD
BIBLIOGRAPHY
Jeerapaet P, Ackerman AB. Histologic patterns of secondary syphilis. Arch Dermatol
1973; 107:3737
Jordaan HF, Louw M. The moth-eaten alopecia of secondary syphilis. A histopathological
study of 12 patients. Am J Dermatopathol 1995; 17:15862
Lee JY, Hsu ML Alopecia syphilitica, a simulator of alopecia areata: histopathology and
differential diagnosis. J Cutan Pothol 1991; 18:8792
1995;22:971 14
Figure 15.4 A relatively mild lymphocytic infiltrate with occasional plasma cells
surrounds the lower portion of a catagen hair in early syphilitic alopecia. Original
magnification 200. Slide courtesy of James W Patterson, MD
Figure 15.5 Residual inflammation is found in the collapsed root sheath (stela) below
a catagen hair. Original magnification 400
Figure 15.6 A collection of lymphocytes has entered the epithelium of this telogen hair.
Figure 15.7 Section from a patient with well-established syphilitic alopecia. The follicles
are very small and inflammation is scanty. Original magnification 40
Figure 15.8 Section from a patient with well-established syphilitic alopecia. Original
magnification 100
CHAPTER 16
Non-scarring alopecia from systemic lupus
erythematosus
Hair loss in systemic lupus erythematosus (SLE) can occur in several forms.
Discoid lesions causing scarring alopecia are the most familiar form of alopecia
to both clinician and dermatopathologist, and will be discussed further in
Chapter 21. Patients with SLE can be severely ill for long periods of time, and so
diffuse hair loss can occur in the form of a telogen effluvium, as described in
Chapter 9.
A form of hair loss in SLE that is fairly common but has received little
attention in the literature is patchy, non-scarring alopecia. This form of hair loss
occurs in patients with severe disease, and the underlying diagnosis of SLE has
already been established or is suspected. Patches of partial or total hair loss are
scattered on the scalp (Figure 16.1), and are associated with mild erythema, but
without evidence of scarring (follicular ostia and surface texture appear normal).
The hairs remaining in the balding patches are almost all telogen hairs or
dystrophic pencil-point anagen hairs (Figure 16.2), a finding diagnostic of an
anagen arrest (described in Chapter 14). If the underlying disease is promptly
brought under control, complete hair regrowth occurs.
A peribulbar mononuclear cell infiltrate is found around anagen hair bulbs, many
of which become miniaturized with the passage of time (Figures 16.316.7). The in
flammatory infiltrate may be more dense than that found in alopecia areata, but
is not always so. The percentage of catagen and telogen hairs is greatly increased,
and may approach 100% (Figure 16.8). Pigment incontinence and a mild
inflammatory infiltrate are often found in the collapsed root sheaths (stelae)
below telogen hairs.
These histological findings are similar to those found in alopecia areata and
essential syphilitic alopecia, and a diagnosis of lupus erythematosus may not be
possible on histological grounds alone. Clinical findings and serological testing
may be required to differentiate reliably between these three forms of nonscarring, reversible, inflammatory alopecia. However, some additional
histological features may help to distinguish SLE from its histological mimics.
For instance, an increase in dermal mucin is sometimes present (Figure 16.9).
Figure 16.1 Young woman with active systemic lupus erythematosus and patchy, nonscarring hair loss. Note the mild, mottled erythema
Figure 16.2 Forcible hair pluck (trichogram) taken from a markedly thinned patch of
scalp in a patient with active systemic lupus erythematosus. The hairs are all telogen
hairs, because all the anagen hair shafts have been shed. Original magnification 40
Although increased mucin may be visible with routine staining, colloidal iron or
similar stains can accentuate the mucin. Inflammation around eccrine glands and
dermal vasculature is often seen in the alopecia of SLE. When inflammation
involves dermal blood vessels, extravasated red blood cells are sometimes found
(Figure 16.10). If present, an especially dense inflammatory infiltrate supports a
diagnosis of lupus erythematosus (Figure 16.11). Finally, focal areas of vacuolar
basilar degeneration, affecting the infundibula of follicles, may be found in some
cases of SLE alopecia (Figure 16.12).
SUMMARY
Clinical correlation: the patient is usually a young adult with severe disease, and
the underlying diagnosis of SLE has already been established or is suspected.
Patches of partial or total hair loss are scattered on the scalp. Mild erythema of
the scalp may be present.
NON-SCARRING ALOPECIA FROM SYSTEMIC LUPUS ERYTHEMATOSUS 149
Figure 16.3 Terminal anagen hairs still predominate in this early lesion of patchy, nonscarring systemic lupus erythematosus. A moderately dense lymphocytic infiltrate
surrounds the lower segments of several anagen hairs, but involves interfollicular blood
vessels as well. Original magnification 100
Figure 16.4 Patchy, non-scarring systemic lupus erythematosus (see Figure 16.3). The
perivascular infiltrate contains some plasma cells. Original magnification 400
Figure 16.5 In this advanced lesion of patchy, non-scarring systemic lupus

erythematosus, the majority of hairs have miniaturized, and their bulbs are found in the
lower to mid-dermis. Lymphocytic inflammation is concentrated in the vicinity of
follicular units. Original magnification 40
May closely resemble alopecia areata and essential syphilitic alopecia

Increased number of catagen and telogen hairs in affected areas (may
approach 100%)
Peribulbar mononuclear cell infiltrate, often more dense than that seen in
alopecia areata
Most anagen hairs are small and surrounded by peribulbar inflammation
Additional possible findings supporting the diagnosis of SLE include:
(a) increased dermal mucin
(b) vacuolar basilar degeneration of the infundibular epithelium
(c) peri-eccrine and perivascular lymphoplasmacytic inflammation
Figure 16.6 Another example of an advanced lesion of patchy, non-scarring systemic

lupus erythematosus (see Figure 16.5). Original magnification 40
(d) extravasated red blood cells around inflamed blood vessels

BIBLIOGRAPHY
Shatley MJ, Walker BL, McMurray RW. Lues and lupus: syphilis mimicking systemic
lupus erythematosus (SLE). Lupus 2001; 10:299303
1995; 22:97114
Sperling LC, Mezebish DS. Hair diseases. Med Clin North Am 1998; 82:115569
Wysenbeek AJ, Leibovici L, Amit M, Weinberger A. Alopecia in systemic lupus
erythematosus. Relation to disease manifestations. J Rheumatol 1991; 18:11856
Figure 16.7 Miniaturized anagen hairs in an advanced lesion of patchy, non-scarring

systemic lupus erythematosus. These small follicles produce little or no hair shaft, and
they closely resemble the nanogen hairs of alopecia areata. Original magnification
200
Figure 16.8 In this advanced lesion of patchy, non-scarring systemic lupus

erythematosus, the majority of hairs are miniaturized and in the catagen/telogen phase.
The inflammation is quite dense as compared with alopecia areata. Original
magnification 200
Figure 16.9 Even without special stains, interstitial dermal mucin is obvious in this
specimen from a patient with patchy, non-scarring systemic lupus erythematosus
Figure 16.10 Deep perivascular inflammation with extravasated red blood cells in a
patient with patchy, non-scarring systemic lupus erythematosus alopecia. Original
magnification 400
Figure 16.11 Deep, dense, chronic inflammation in a patient with patchy, nonscarring systemic lupus erythematosus alopecia. Original magnification 200
Figure 16.12 Mild and focal vacuolar interface change affecting the follicular
infundibulum in a patient with patchy, non-scarring systemic lupus erythematosus
CHAPTER 17
Loose anagen hair syndrome
Although loose anagen hair syndrome (LAHS) was first described in the late
1980s, it is a fairly common form of non-scarring hair loss. Lack of familiarity with
the condition is the major obstacle to establishing the diagnosis. Most patients
are first diagnosed at the age of 25 when they are brought to a physician with
the complaint of thin, uneven hair with an abnormal texture (Figures 17.117.3).
Parents often state that the childs hair wont grow.
Anagen hairs can be easily and painlessly extracted from the scalp by gentle
traction. Extracted hairs show a characteristic ruffling of the hair shaft cuticle
(Figure 17.4). The inner and outer root sheaths are left behind in the scalp when
anagen hairs are extracted. Some authors have found an increased telogen count
(> 20%) in patients with LAHS, but others have found a decreased count (<
5%). This issue will require more careful study in large numbers of patients.
There are no reports of inflammation in biopsy specimens from LAHS patients.
The internal root sheath has been reported to show a crumbling degeneration as
well as premature keratinization. Crumbling degeneration may refer to the
numerous fractures that may occur within the cornified inner root sheath during
tissue processing (Figures 17.5 and 17.6). This artifact of processing can also be
seen in normal specimens, but is more common and prominent in LAHS.
Varying degrees of abnormal (i.e., excessive) artifactual separation can be seen
between the hair cuticle and cortex, between the hair cuticle and inner root
sheath cuticle, within the inner root sheath, and between the inner and outer root
sheaths (Figures 17.717.9). This clefting is not specific for LAHS, and similar
changes can occasionally be found in specimens from normal scalps. However,
artifactual clefting appears to be a prominent and consistent feature found in
LAHS.
It must be emphasized that clefting found between the cornified hair shaft and
inner root sheath is an artifact of processing that occurs in almost all normal as well
as abnormal follicles. It is therefore irrelevant and should be ignored.
Occasionally, incomplete follicular anatomy resembling trichotillomania is
found. When this occurs, only the hair shaft is absent, and the residual inner and
Figure 17.1 A 4-year-old boy with loose anagen hair syndrome. The hair is focally
thinned with locks that are uneven in length. Some spangling of the hair is evident, caused
by the irregular grooves and twists in some of the hair shafts
outer root sheaths are collapsed (Figure 17.10). This finding is hardly surprising,
because the shafts can be easily and painlessly extracted in children with LAHS,
and sites of recent depilation may be chosen for biopsy.
Although most hair shafts in LAHS retain the normal oval or circular shape,
some shafts have unusual polygonal shapes (Figures 17.11 and 17.12). This
corresponds to the grooving of hair shafts that can often be found in LAHS. A
few patients with LAHS have more prominent hair shaft grooving, affecting
most hairs. In some specimens from patients with LAHS, an increased telogen
count is found.
SUMMARY
Clinical correlation: child with areas of slightly thinned, somewhat unruly hair.
Parents complain that childs hair wont grow.
Degenerative changes and abnormal cornification of inner root sheath

Clefting within the inner root sheath (IRS), between the non-cornified cortex
and IRS, between the inner and outer root sheaths, and between the outer root
sheath and fibrous sheath
In some, but not all specimens the following features may be seen: increased
telogen count (> 20%); absent hair shafts with collapsed root sheaths; unusual
hair shaft shapes
No significant inflammation
LOOSE ANAGEN HAIR SYNDROME 157
Figure 17.2 A 4-year-old girl with loose anagen hair syndrome. Most reported patients
have been girls with blond hair. The hair is somewhat thinned and has a windblown
appearance
BIBLIOGRAPHY
Baden HP, Kvedar JC, Magro CM. Loose anagen hair as a cause of hereditary hair loss in
children. Arch Dermatol 1992; 128:134953
Boyer JD, Cobb MW, Sperling LC, Rushin JM. Loose anagen hair syndrome mimicking
the uncombable hair syndrome. Cutis 1996; 57:l 1112
Chapman DM, Miller RA. An objective measurement of the anchoring strength of anagen
hair in an adult with the loose anagen hair syndrome. J Cutan Pathol 1996; 23:
28892
LiVW, Baden HP, Kvedar JC. Loose anagen syndrome and loose anagen hair. Dermatol
Clin 1996; 14:74551
Nunez J, Grande K, Hsu S. Alopecia areata with features of loose anagen hair. Pediatr
Dermatol 1999; 16:4602
ODonnell BP, Sperling LC, James WD. Loose anagen hair syndrome. Int J Dermatol
1992; 31:1079
Price VH, Gummer CL Loose anagen syndrome. J Am Acad Dermatol 1989; 20:24956
Pride HB, Tunnessen WW Jr. Picture of the month. Loose anagen syndrome. Arch
Pediatr Adolesc Med 1995; 149: 81920
Figure 17.3 Unruly, twisted hair in a girl with loose anagen hair syndrome (LAHS). This
degree of hair shaft abnormality is exceptional for LAHS. Photograph courtesy of Jeffrey
Miller, MD
Sinclair R, Cargnello J, Chow CW. Loose anagen syndrome. Exp Dermatol 1999; 8:
2978
Tosti A, Piraccini BM. Loose anagen hair syndrome and loose anagen hair. Arch Dermatol
2002; 138:5212
Tosti A, Peluso AM, Misciali C, Venturo N, Patrizi A, Fanti PA. Loose anagen hair. Arch
Dermatol 1997; 133:108993
Figure 17.4 Anagen hair gently extracted from the scalp of a child with loose anagen hair
syndrome. The soft hair matrix and suprabulbar zone is prone to kinking during extraction,
resulting in a hockey stick appearance. There is a ruffling of the hair shaft cuticle where
it separates from the inner root sheath. Original magnification 100
Figure 17.5 Numerous fractures within the inner root sheath are commonly found in loose
anagen hair syndrome. Original magnification 400
Figure 17.6 Inner root sheath in loose anagen hair syndrome, showing numerous
fractures. Original magnification400
Figure 17.7 Several variations of artifactual clefting can be seen in loose anagen hair
syndrome. Here clefting has occurred between the hair cortex and the inner root sheath.
Figure 17.8 Artifactual clefting in loose anagen hair syndrome. Here clefts between inner
and outer root sheaths are seen. Original magnification 400
Figure 17.9 A circumferential cleft has occurred within the inner root sheath between
Henles and Huxleys layer. Original magnification 400
Figure 17.10 In this specimen from a child with loose anagen hair syndrome, hair shafts
have been previously extracted from two follicles, and the inner root sheaths have
collapsed inward. Original magnification 200. Slide courtesy of Jeffrey Miller, MD
CHAPTER 18
Central, centrifugal scarring alopecia
The term central, centrifugal scarring alopecia (CCSA) was recently coined to
incorporate several variants of inflammatory, scarring alopecia. The difference
between these variants may be due to racial differences or the well-recognized
variability in immune responses between individuals. The entities grouped under
CCSA include pseudopelade (not Brocqs pseudopelade), the follicular
degeneration syndrome, and folliculitis decalvans. As variants of CCSA, they
have the following features in common:
(1) They are chronic and progressive, with eventual spontaneous burn out
after years or decades;
(2) They are predominantly centered on the crown or vertex;
(3) They progress in a roughly symmetrical fashion, with the most active
disease activity occurring in a peripheral zone of variable width, surrounding
a central, alopecic zone;
(4) They show both clinical and histological evidence of inflammation in the
active, peripheral zone.
Over the years, CCSA has been given several names, because the condition
exhibits a spectrum of inflammation. Patients with highly inflammatory disease,
as evidenced by pustule formation, crusting, intense erythema and bacterial
superinfection, have usually been labeled with folliculitis decalvans. Patients
with more indolent disease, characterized by perifollicular scaling and
occasional papule formation, have been labeled with pseudopelade or the
follicular degeneration syndrome. Most patients described as having
pseudopelade have been Caucasians, and most patients labeled with the
follicular degeneration syndrome have been dark-skinned persons of African
descent (Blacks; African Americans). However, clinically and especially
histologically, the similarity of CCSA between racial groups far exceeds any
differences.
CCSA is the most common form of scarring alopecia in any population that
includes significant numbers of Black patients. Among African Americans,
CCSA is responsible for more cases of scarring alopecia than all other forms
combined. The majority of Black patients with CCSA are women, with a female:
Figure 18.1 Early central, centrifugal scarring alopecia emerges as a zone of partial hair
thinning centered on the crown or vertex. Permanent hair loss is evidenced by the loss of
follicular ostia between remaining follicles
Figure 18.2 Even in fairly advanced central, centrifugal scarring alopecia, evidence of
clinical inflammation such as papules and pustules may be absent,and the patient may be
misdiagnosed as having androgenetic alopecia
male ratio of about 3:1. The average age at presentation is 36 years for women
and 31 years for men, although most patients have had progressive disease for
years or decades before they seek medical attention. The disease invariably
begins and remains most severe on the crown or vertex of the scalp (Figure 18.1),
gradually expanding in a centrifugal fashion. Even when the amount of hair loss
is dramatic, symptoms may be mild or absent. Most patients note only mild,
episodic pruritus or tenderness of involved areas. Virtually all African American
women with CCSA are using or have used chemical hair relaxers for styling
purposes, but few men have used anything except pomades. Patients experience
progression of the disease even after all chemical treatments (if any)
are discontinued. Caustic cosmetics may aggravate the disease or hasten its
progression, but cannot fully explain its pathogenesis.
The crown and/or vertex of the scalp shows a symmetrical zone of partial or
complete alopecia. When inflammation is subtle, CCSA may be incorrectly
diagnosed as androgenetic alopecia (Figure 18.2). The follicular ostia between
remaining hairs are obliterated, and the scalp is smooth and shiny, evidence of
scarring alopecia.
CENTRAL, CENTRIFUGAL SCARRING ALOPECIA 165
Figure 18.3 In the folliculitis decalvans variant of central, centrifugal scarring alopecia,
numerous papules and pustules surround a zone that is almost completely devoid of hair
A few isolated hairs, some showing polytrichia (tufting), may be stranded in

the otherwise denuded central zone. Early or mild disease may be manifest as a
partially bald patch only a few centimeters in diameter (as in Figure 18.1). Longstanding or severe disease can result in hair loss covering the entire crown of the
scalp. As the examiner moves from the center of involvement, a gradual increase
in hair density is noted, merging gradually with the surrounding normal scalp. In
this transitional zone, a few inflammatory, follicular papules may be found. Even
normal scalp skin may show small foci of alopecia and an occasional follicular
papule or some perifollicular scaling.
Pustules and crusting may be found in the minority of patients who suffer from
rapidly progressive disease or bacterial superinfection (folliculitis decalvans;
Figure 18.3). It should be noted that some authors have used the term folliculitis
decalvans to describe any form of dramatic or highly inflammatory scarring
alopecia.
Pustular lesions come and go during the course of the disease. The pustules of
CCSA are most likely a manifestation of bacterial superinfection and/or the
immune response of the patient to degenerating follicular components. However,
some authors have argued that folliculitis decalvans is a primary
staphylococcal infection. In any case, a short course of antibiotics or systemic
Figure 18.4 The sections shown in Figures 18.418.7 are well below the level of the
isthmus and eccrine coils. Here, two follicles are shown that have undergone premature
desquamation of the inner root sheath. Original magnification 400
corticosteroids can temporarily eliminate the purulent component of CCSA.

Inflamed lesions can be multifocal, but eventually merge into one larger patch on
the crown or vertex. An expanding zone of alopecia with peripheral pustules and
crusting is not diagnostic of CCSA, and can be seen in tinea capitis (kerion) and
true bacterial infections of the scalp. When these latter conditions are excluded,
the majority of patients will prove to have CCSA.
If the central, bald zone is sampled, the histological findings will be those of a
burnt out scarring alopecia (see Chapter 22). The most productive area for
biopsy is the peripheral, partially alopecic fringe, but even clinically normal
scalp may be diseased at the microscopic level. Not every follicle in a given area
is involved simultaneously. A 4-mm punch biopsy specimen may contain only
one or two diagnostic follicles. This is because the involved follicles are
selectively destroyed, with sparing of the relatively normal follicles. Although an
occasional vertical section may reveal an involved hair, in most cases transverse
sections at several levels are required for a definitive diagnosis.
Figure 18.5 One of four follicles, upper right, has undergone premature desquamation of
the inner root sheath. Original magnification 100
The most distinctive and earliest histological finding is premature

desquamation of the inner root sheath. This finding has been most often
demonstrated in Black patients, but can be found in all races. Normally, the inner
root sheath desquamates and disappears within the mid- to upper isthmus, which
is usually located in the upper half of the dermis. In many cases of CCSA, the
inner root sheath of an involved follicle desquamates in the lower half of the
dermis, sometimes as low as (or below) the dermal-subcutaneous
junction (Figures 18.418.7). Desquamation of the inner root sheath below the
level of the eccrine coils can be regarded as premature because it is rarely
found in a normal scalp. Premature desquamation of the inner root sheath can be
observed in follicles that are other-wise normal, suggesting that it represents a very
early phase of the disease. It can occasionally be seen in other conditions in
which follicles are subject to marked inflammation and degenerative changes.
However, as a manifestation of early disease, premature inner root sheath
desquamation is unique to CCSA. This anatomical defect is probably an
important component in the pathogenesis of the disease and may predispose the
affected follicles to injury.
Figure 18.6 The follicle from Figure 18.5 that had undergone premature desquamation of
the inner root sheath. Original magnification 200
As the disease evolves in clinically abnormal scalp skin, involved follicles also
demonstrate some or all of the following histological features: eccentric epithelial
atrophy (thinning) with hair shafts in close proximity to the dermis (Figures 18.8
and 18.9); concentric lamellar fibroplasia (onion skin-like fibrosis) of affected
follicles (Figures 18.10 and 18.11); variably dense lymphocytic perifollicular
inflammation, primarily at the level of the upper isthmus and lower infundibulum
(Figures 18.1218.14); occasional fusion of infundibula (polytrichia;
Figures 18.15 and 18.16); and in advanced lesions, total destruction of the
follicular epithelium with retained hair shaft fragments and granulomatous
inflammation. Inter-face alteration of the follicular epithelium is not found. To
date, the immunofluorescent findings in patients with CCSA have not been
critically studied.
When highly inflammatory disease with pustule formation is present
(folliculitis decalvans), the microscopic findings in pustular lesions include
intrafollicular and perifollicular infiltrates rich in neutrophils as well as
lymphocytes (Figures 18.1718.21).
However, if non-pustular lesions at the active periphery are sampled, or if the
biopsy is performed during a period of suppressive therapy, the histological
Figure 18.7 A normal follicle (lower left) and two that have undergone premature
desquamation of the inner root sheath. Original magnification 100
picture is identical to that of other forms of CCSA (Figure 18.22). If early lesions
are sampled, all the histological changes described for CCSA can be found in
folliculitis decalvans.
The only unique histological characteristic of CCSA is premature
desquamation of the inner root sheath. The remainder of the histological features
can be found in other forms of inflammatory, scarring alopecia, and are therefore
suggestive, but not diagnostic.
SUMMARY
Clinical correlation: an adult, most often a Black woman, with a progressive,
permanent loss of scalp hair starting on the central crown or vertex. A spectrum
of clinical inflammation exists, ranging from minimal to highly inflamed, with
marked erythema, pustules and crusting (folliculitis decalvans).
Histological findings: the earliest finding is premature desquamation of the
inner root sheath. This may be found even when normal-appearing scalp skin or
perilesional skin is sampled. In more advanced lesions, some or all of the
following features are usually seen:
Figure 18.8 Once a follicle has undergone premature desquamation of the inner root
sheath, it is prone to eccentric epithelial atrophy (thinning) with a hair shaft in close
proximity to the dermis. Original magnification 200
Variably dense lymphocytic perifollicular inflammation, primarily at the level

of the upper isthmus and lower infundibulum
Eccentric epithelial atrophy (thinning), with hair shafts in close proximity to
the dermis
Occasional fusion of infundibula (polytrichia)
Concentric lamellar fibroplasia (onion skin-like fibrosis) of affected follicles
In advanced lesions, total destruction of the follicular epithelium with retained
hair shaft fragments and granulomatous inflammation
Replacement of the follicular epithelium by connective tissue (follicular
scars)
BIBLIOGRAPHY
Brooke RC, Griffiths CE. Folliculitis decalvans. Clin Exp Dermatol 2001; 26:1202
Powell JJ, Dawber RP, Gatter K. Folliculitis decalvans including tufted folliculitis:
clinical, histological and therapeutic findings. Br J Dermotol 1999; 140:32833
Sperling L, Sau P. The follicular degeneration syndrome in black patients: hot comb
alopecia revisited and revised. Arch Dermatol 1992; 128:6874
Figure 18.9 Two abnormal follicles in different stages of evolution; one follicle (lower
left) shows eccentric epithelial atrophy and the second (lower right) shows total epithelial
destruction with a retained hair shaft. A normal follicle (upper-most) is present for
Sperling L, Skelton H, Smith K, Sau R Friedman K. The follicular degeneration syndrome
in men. Arch Dermatol 1994; 130: 7639
Sperling L, Solomon A, Whiting D. A new look at scarring alopecia. Arch Dermatol 2000;
136:23542
criteria. J Cutan Pathol 1994;21:97109
Whiting DA. Cicatricial alopecia:clinico-pathological findings and treatment. Clin
Dermatol 2001; 19:21125
Figure 18.10 Vertical section of a follicle showing concentric lamellar fibroplasia (as
well as epithelial atrophy) at the level of the upper isthmus/lower infundibulum. Original
magnification 200
Figure 18.11 Transverse section of a follicle similar to that in Figure 18.10. Original
magnification 200
Figure 18.12 Perifollicular lymphocytic inflammation is usually found in association with

epithelial thinning and lamellar fibroplasia, and is most intense at the level of the isthmus
and lower infundibulum. Original magnification 200
Figure 18.13 Another example of perifollicular lymphocytic inflammation. Original

magnification 200
Figure 18.14 One of the two follicles (left side) has an intact inner root sheath and is not
affected by inflammation or fibroplasia. Original magnification 200
Figure 18.15 The infundibula of several adjacent, inflamed follicles may merge, resulting
in clinical polytrichia. Original magnification 200
Figure 18.16 During the healing process a single, common enlarged infundibulum may
form, resulting in polytrichia. Original magnification 200
Figure 18.17 Biopsy specimen taken from a crusted, pustular lesion in a patient with the
folliculitis decalvans variant of central, centrifugal scarring alopecia. Much of the
follicular epithelium has been damaged or destroyed by a dense inflammatory infiltrate
composed predominantly of neutrophils. (See Figures 18.1818.20.) Original
magnification 40
Figure 18.18 Higher power view of the section shown in Figure 18.17. Original
magnification 200
Figure 18.19 Special stain for bacteria reveals colonies of staphylococci. Original
magnification 400
Figure 18.20 Special stain for fungi reveals clusters of fungal spores typical of
Pityrosporum contained within the infundibulum and overlying scale/crust. The
findings in Figures 18.1718.21 are non-specific end stage changes, and can be
found in any highly inflammatory form of scarring alopecia. Original magnification
400
Figure 18.21 Pustular lesions in highly inflammatory cases of central, centrifugal

scarring alopecia are rich in neutrophils and resemble a bacterial folliculitis. Original
magnification 100
CHAPTER 19
Lichen planopilaris
The clinical course of lichen planopilaris (LPP) may be insidious or fulminant,

and the pattern of scalp hair loss is highly variable. Most commonly, there are
several scattered foci of partial hair loss (Figures 19.1 and 19.2). Perifollicular
erythema and scaling are almost always present (Figure 19.3). A pattern of hair
loss suggestive of central, centrifugal scarring alopecia (Figure 19.4) or
pseudopelade of Brocq can also occur. As in all cases of inflammatory scarring
alopecia, LPP can heal with the formation of polytrichia (tufting; Figure 19.5).
Clearly, there can be some clinical overlap with other forms of scarring alopecia.
Therefore, the diagnosis of LLP cannot be based on clinical features alone.
Patients with indolent scalp disease may be asymptomatic, but itching and
tenderness are often present. Patients who also have lesions of lichen planus on
the skin or mucosa may have symptoms related to these lesions.
The Graham-Little syndrome (scarring alopecia of the scalp, loss of pubic and
axillary hair, and the rapid development of keratosis pilaris) is considered by
some to be a variant of LPP. However, typical lichen planus lesions are not
found and the histological findings are usually not lichenoid. It is unclear whether
this condition is related to LPP. In any case, the Graham-Little syndrome is rare.
HISTOLOGICAL FEATURES
Typical LPP shows a band-like mononuclear cell infiltrate obscuring the
interface between follicular epithelium and dermis (Figure 19.6). Vacuolar
alteration at the interface and wedge-shaped hypergranulosis within affected
infundibula is typical. The epithelial-adventitial junction often shows prominent
dyskeratosis with individually necrotic, polygonal basal keratinocytes
(Figure 19.7). Colloid or Civatte bodies are occasionally found as part of the
interface alteration, but this occurs less commonly in disease of the follicular
epithelium than of the epidermis.
Inflammation affects the upper portion of the follicle (infundibulum and
isthmus) most severely (Figures 19.819.10), but inflammation may occasionally
extend down the length of the follicle. Perivascular and perieccrine lymphocytic
infiltrates of the mid- and deep dermis (as seen in discoid lupus erythematosus) are
absent in LPP. Occasionally, interfollicular changes of lichen planus are found
Figure 19.1 Most commonly, the scalp lesions of lichen planopilaris are irregularly
shaped and widely scattered over the scalp
Figure 19.2 A confetti-like pattern of numerous small and widely distributed lesions is a
relatively common clinical variant of lichen planopilaris
Figure 19.3 Before the hair is completely destroyed, perifollicular erythema and scaling
indicate the presence of active lichen planopilaris
(Figures 19.1119.13). When present, interfollicular involvement strongly

supports a diagnosis of LPP.
Eventually the infundibulum and isthmus become distended and plugged with
keratinous debris. With time, vacuolar interface change subsides, the layer of
perifollicular fibrosis becomes thicker, and the lymphocytic infiltrate seems to
back away from the follicle (Figures 19.14 and 19.15). Basilar keratinocytes
LICHEN PLANOPILARIS 183
Figure 19.4 This patient with lichen planopilaris has extensive hair loss centered on the
crown of the scalp, resembling a severe case of central, centrifugal scarring alopecia
become pink and flattened, and an artifactual cleft between epithelium and
stroma is often found. In fact, the epithelium may appear to be floating within
the cleft (Figure 19.16). Although these later changes are often seen in patients
with long-standing LPP, they are not pathognomonic and can be observed in
other forms of inflammatory, scarring alopecia.
In time, the follicle is entirely destroyed. At first, retained hair shafts fragment
and a granulomatous response is observed, but eventually the follicles are
replaced by columns of connective tissue, giving the appearance of a burnt out
scarring alopecia (Figure 19.17; see also Chapter 22). As is the case in all forms
of inflammatory, scarring alopecia, the healing process may result in clinical and
histological polytrichia (Figure 19.18).
Grouped globular immunofluorescence (usually IgM), especially when found
adjacent to the follicular epithelium, is the characteristic pattern seen in LPP
(Figure 19.19). Linear deposits of immunoreactants are typical of lupus
erythematosus. This distinction can be important, because the scarring alopecia
of LPP and discoid lupus erythematosus may resemble each other both clinically
and histologically.
Figure 19.5 In this patient, lesions of lichen planopilaris have resulted in polytrichia
Because of poor site selection or sampling error, often the only changes found
are perifollicular fibroplasia and chronic inflammation. These changes are nonspecific and cannot be considered diagnostic. Additional biopsies are required to
establish the diagnosis whenever non-specific changes are found. However,
typical clinical lesions of lichen planus on other parts of the body strongly
support the diagnosis of LPP.
SUMMARY
Clinical correlation: various patterns of hair loss are seen, but most commonly
there are scattered foci of partial hair loss. Perifollicular erythema and scaling are
common to all cases. Lichen planus lesions elsewhere on the body support the
diagnosis of LPP on the scalp.
Interface lichenoid dermatitis affecting the infundibulum and isthmus

The presence of squamatized basal layer with artifactual clefting between
epithelium and dermis is often seen
Figure 19.6 The early changes of lichen planopilaris include a mononuclear cell
infiltrate obscuring the interface between epithelium and dermis. Vacuolar alteration of
the outermost layer of the outer root sheath is prominent in the early stages of the disease.
Figure 19.7 Another involved follicle, demonstrating early changes of lichen

planopilaris, has dyskeratotic or necrotic, polygonal basal keratinocytes and a few colloid
bodies. Original magnification 400
Colloid bodies and interfollicular changes of lichen planus are sometimes

found and support the diagnosis
Perifollicular chronic inflammation and fibroplasia are sometimes the only
changes seen, but cannot be considered diagnostic
Grouped globular immunofluorescence (usually IgM), especially when found
adjacent to the follicular epithelium, is the characteristic pattern seen in lichen
planopilaris
BIBLIOGRAPHY
Amato L, Mei S, Massi D, Gallerani I, Fabbri R Cicatricial alopecia; a dermatopathologic
and immunopathologic study of 33 patients (pseudopelade of Brocq is not a specific
clinicopathologic entity). Int J Dermatol 2002; 41:815
Annessi G, Lombardo G, Gobello T, Puddu R A clinicopathologic study of scarring
alopecia due to lichen planus: comparison with scarring alopecia in discoid lupus
erythematosus and pseudopelade. Am J Dermatopathol 1999; 21:32431
Figure 19.8 Transverse sections (see also Figures 19.9 and 19.10) taken at multiple levels
clearly demonstrate the depth of inflammation in lichen planopilaris. In this specimen,
inflammation is most intense at the level of the upper isthmus. Original magnification 40
Figure 19.9 Inflammation is relatively sparse at the infundibular level. Original

magnification 40
Figure 19.10 Transverse section at the suprabulbar level, showing relatively sparse
inflammation. This is a typical pattern for lichen planopilaris. Original magnification 40
Elston DM, Bergfeld WF. Cicatricial alopecia (and other causes of permanent alopecia).
In Olsen EA, ed. Disorders of Hair Growth. New York:McGraw-Hill, 1994:
285314
Elston DM, McCollough ML, Warschaw KE, Bergfeld WF. Elastic tissue in scars and
alopecia. J Cutan Pathol 2000; 27: 14752
Headington JT. Cicatricial alopecia. Dermatol Clin 1996; 14:77382
Figure 19.11 This specimen from a patient with lichen planopilaris had typical follicular
changes but also interfollicular epidermal involvement. Vacuolar interface alteration,
numerous colloid bodies, and focal hypergranulosis can be seen. Original magnification
200
Figure 19.12 Another view of the specimen shown in Figure 19.11. Original
magnification 400
loannides D, Bystryn JC. Immunofluorescence abnormalities in lichen planopilaris.Arch
Dermatol 1992; 128:21416
Matta M, Kibbi AG, Khattar J, Salman SM, Zaynoun ST. Lichen planopilaris: a
clinicopathologic study. J Am Acad Dermatol 1990; 22:5948
Mehregan DA,Van Hale HM, Muller SA. Lichen planopilaris: clinical and pathologic
study of forty-five patients. J Am Acad Dermatol 1992; 27:93542
Silvers DN, Katz BE,Young AW. Pseudopelade of Brocq is lichen planopilaris: report of
four cases that support this nosology. Cutis 1993; 51:99105
Smith WB, Grabski WJ, McCollough ML, Davis TL Immunofluorescence findings in
lichen planopilaris: a contrasting experience. Arch Dermatol 1992; 128:14056
136:23542
Thomsen HK. Lichen planopilaris or lupus? J Am Acad Dermatol 1999; 40:284
Waldorf DS. Lichen planopilaris. Histopathologic study of disease. Progression to
scarring alopecia. Arch Dermatol 1966; 93:68491
Whiting DA. Cicatricial alopecia: clinico-pathological findings and treatment. Clin
Dermatol 2001; 19:211 -25
Figure 19.13 Another view of the specimen shown in Figures 19.11 and 19.12. Original
magnification 400
Figure 19.14 Later stage histological findings in lichen planopilaris.Vacuolar interface

change is less evident, the layer of perifollicullar fibrosis is quite thick, and the
lymphocytic infiltrate has moved outside the zone of fibrosis. Original magnification
200
Figure 19.15 Later stage lichen planopilaris, as in Figure 19.14. Original magnification
400
Figure 19.16 The more advanced changes seen in lichen planopilaris include prominent
artifactual clefting between epithelium and perifollicular connective tissue. Original
magnification 400
Figure 19.17 End-stage lichen planopilaris. The epithelium has been completely
destroyed. After the residual hair shaft has been resorbed, inflammation will subside and a
column of connective tissue will remain. Original magnification 400
Figure 19.18 In this end-stage specimen of lichen planopilaris, the follicular infundibula
of several adjacent follicles have merged (polytrichia) to form a single, enlarged ostium.
Figure 19.19 Immunofiuorescent staining for IgG in a specimen from a patient with
lichen planopilaris. Globular, clustered colloid bodies concentrated at the lower half of the
infundibulum are highlighted bright green. Linear staining of the epithelium is absent.
Slide courtesy of Kathleen David-Bajar, MD
CHAPTER 20
Frontal fibrosing alopecia
This condition was recently reported in several Australian, postmenopausal,

Caucasian women. The disease has yet to be reported in the USA. Patients are
elderly women (mean age 67 years) with progressive hair loss along the anterior
hairline and the eyebrows. The histological features are similar to those found in
lichen planopilaris. Frontal fibrosing alopecia appears to be just one of several
clinical patterns of hair loss that can be seen in lichen planopilaris. However,
lesions of lichen planus are not found in these patients and the lichenoid
inflammation does not affect the interfollicular epidermis.
BIBLIOGRAPHY
Kossard S, Lee MS, Wilkinson B. Postmenopausal frontal fibrosing alopecia: a frontal
variant of lichen planopilaris. J Am Acad Dermatol 1997; 36:5966
Trueb RM, Torricelli R. Lichen planopilaris simulating postmenopausal frontal fibrosing
alopecia. Hautarzt 1998; 49: 38891
CHAPTER 21
Chronic cutaneous lupus erythematosus
(discoid lupus erythematosus)
The term chronic cutaneous lupus erythematosus (CCLE) is preferred to

discoid lupus erythematosus (DLE) because it is more inclusive. Nevertheless,
DLE enjoys such common usage that the two terms are used interchangeably.
CCLE usually occurs in adults, and is more common in women. Although
lesions of CCLE are often found in patients with systemic lupus erythematosus
(SLE), the majority of patients with CCLE do not have systemic disease. Among
patients with skin disease only, about 50% will have scalp lesions, and very few
of these patients will ever progress to SLE. Although itching or tenderness is
common, the condition may be asymptomatic. The presence of lesions outside
the scalp gready simplifies diagnosis.
Scalp involvement may resemble classic DLE lesions, with alopecia,
erythema, epidermal atrophy and dilated, plugged follicular ostia. Central
hypopigmentation and peripheral hyperpigmentation are characteristic of lesions
in dark-skinned individuals (Figure 21.1). Plaques of CCLE may merge to form
large, irregularly shaped zones of scarring alopecia, and in some cases may be
centered on the crown or vertex, resembling central, centrifugal scarring alopecia
(Figure 21.2). However, some cases of CCLE first present as clinically nonscarring or even non-inflammatory alopecia that may resemble alopecia areata
(Figure 21.3). Long-standing, burnt out disease confined to the scalp may be
impossible to differentiate from lichen planopilaris or Brocqs pseudopelade
(Figure 21.4). Because CCLE of the scalp can have many clinical patterns, the
diagnosis cannot be based on clinical findings alone.
Vacuolar interface alteration of the epidermis and follicular epithelium is typical,
although the epidermis may be spared in scalp lesions (Figures 21.521.9). The
degree of perifollicular inflammation associated with the vacuolar interface
change is highly variable. There can be dramatic vacuolar alteration with almost
no inflammation, or there can be a dense, band-like lymphocytic infiltrate
suggestive of lichen planopilaris (LPP). Dyskeratosis and colloid (Civatte)
bodies are occasionally seen, but less commonly than in LPP. However,
moderate to dense, superficial and deep chronic inflammation, often including
CHRONIC CUTANEOUS LUPUS ERYTHEMATOSUS (DISCOID LUPUS ERYTHEMATOSUS)

195
Figure 21.1 Typical plaque of chronic cutaneous lupus erythematosus on the scalp of a
dark-skinned woman
Figure 21.2 Large plaque of chronic cutaneous lupus erythematosus centered on the
crown of the scalp. This pattern can easily be confused with central, centrifugal scarring
alopecia
plasma cells, is seen in both perivascular and periadnexal locations

(Figure 21.10). Perifollicular inflammation is often most severe at the level of the
infundibulum but can extend down to the follicular bulbs (Figure 21.11), and
inflammatory cells may invade the follicular epithelium. Residual inflammation
may be found in and around the follicular tracts below follicles that have entered
the telogen phase or have been destroyed (Figures 21.12 and 21.13). Increased
dermal mucin is often present (Figure 21.14) and is helpful in differentiating
CCLE from LPP. Additional findings that support a diagnosis of CCLE over LPP
include the presence of a focally thinned but hyperkeratotic epidermis, a
thickened basement membrane, the absence of wedge-shaped hypergranulosis
and an infiltrate containing numerous plasma cells (Figure 21.15).
Although artifactual clefting between the follicular epithelium and the stroma
is typical of LPP, it can also be seen in CCLE (Figure 21.16). Therefore, this
histological feature cannot be used to separate the two entities. Granular deposits
of IgG and C3 (less commonly IgM or IgA) at the dermoepidermal junction and/
or the junction of the follicular epithelium and dermis are typical of CCLE
Figure 21.3 Large patch of chronic cutaneous lupus erythematosus resembling alopecia
areata. In the center of the patch is a dyspigmented and slightly atrophic plaque that
serves as a clue to the correct diagnosis
Figure 21.4 Burnt out lesion of chronic cutaneous lupus erythematosus (CCLE),
indistinguishable clinically from Brocqs alopecia or from other forms of end-stage
scarring hair loss. This patient with mild, chronic systemic lupus erythematosus had an
earlier biopsy specimen taken from this site that was diagnostic of CCLE
(Figures 21.17 and 21.18). Globular deposits of IgM representing colloid bodies
may be present, but not as commonly as in LPP.
SUMMARY
Clinical correlation: The diagnosis of CCLE requires histological confirmation
and cannot be based solely on the clinical appearance of scalp lesions. These
may resemble classic DLE lesions, with alopecia, erythema, epidermal atrophy
and dilated, plugged follicular ostia. Central hypopigmentation and peripheral
hyperpigmentation are commonly seen in dark-skinned individuals. The
distribution and degree of clinical inflammation varies among patients, and
plaques of CCLE may result in patterns resembling alopecia areata, LPP, central,
centrifugal scarring alopecia and Brocqs pseudopelade.

197
Figure 21.5 Vacuolar interface alteration of the follicular epithelium is a constant feature
of chronic cutaneous lupus erythematosus, but here and in Figure 21.6 the degree of
inflammation is scanty. Original magnification 200
Figure 21.6 Chronic cutaneous lupus erythematosus, with vacuolar interface alteration
and scanty inflammation, as in Figure 21.5. Original magnification 400
Vacuolar interface alteration of the epidermis and follicular epithelium is

typical, although the epidermis may be spared in lesions of DLE involving the
scalp.
The interface change is usually vacuolar rather than lichenoid. Dyskeratosis
and colloid (Civatte) bodies are occasionally seen, but less commonly than in
LPP.
Moderate to dense chronic inflammation, often including plasma cells, is seen
in both perivascular and periadnexal locations.
When perifollicular inflammation is noted, it is usually most severe at the
level of the infundibulum, and inflammatory cells may invade the follicular
epithelium.
Similar inflammation may be found in and around the follicular tracts that lie
below follicles that are in the telogen phase or have been destroyed.
Increased dermal mucin is often present and is helpful in differentiating DLE
from LPP.
Granular deposits of IgG and C3 (less commonly IgM or IgA) at the
dermoepidermal junction and/or the junction of the follicular epithelium and
Figure 21.7 Chronic cutaneous lupus erythematosus, with moderate inflammation.

dermis are typical of CCLE. Globular deposits of IgM representing colloid

bodies may be present, but not as commonly as in LPP.
BIBLIOGRAPHY
Annessi G, Lombardo G, Gobello T, Puddu P. A clinicopathologic study of scarring
alopecia due to lichen planus: comparison with scarring alopecia in discoid lupus
erythematosus and pseudopelade. Am J Dermatopathol 1999; 21:32431
Headington JT. Cicatricial alopecia. Dermatol Clin 1996; 14:77382
136:23542
criteria. J Cutan Pathol 1994; 21:97109
Whiting DA. Cicatricial alopecia: clinico-pathological findings and treatment. Clin
Dermatol 2001; 19:211125
Wilson CL, Burge SM, Dean D, Dawber RP. Scarring alopecia in discoid lupus
erythematosus. Br J Dermatol 1992; 126:30714

199
Figure 21.8 Chronic cutaneous lupus erythematosus, with dense inflammation. Original
magnification 200
Yell JA, Mbuagbaw J, Burge SM. Cutaneous manifestations of systemic lupus
erythematosus. Br J Dermatol 1996; 135:35562
Figure 21.9 Chronic cutaneous lupus erythematosus, with dense inflammation, as in

Figure 21.10 Lymphoplasmacytic inflammation often surrounds eccrine glands as well as

follicles. Original magnification 400

201
Figure 21.11 Inflammation may extend down to the follicular bulbs. Original
magnification 40
Figure 21.12 Follicular stela infiltrated by copious plasma cells and lymphocytes.
Figure 21.13 Follicular stela infiltrated by copious plasma cells and lymphocytes.

203
Figure 21.14 An increase in interfollicular dermal mucin (here stained blue) is commonly
found in chronic cutaneous lupus erythematosus. Colloidal iron stain, original
magnification 400
Figure 21.15 Epidermal involvement in a scalp biopsy from a patient with chronic
cutaneous lupus erythematosus (CCLE). Hyperkeratosis with hypogranulosis and
epidermal thinning help to differentiate CCLE from lichen planopilaris. Original
magnification 200
Figure 21.16 Artifactual clefting between the follicular epithelium and the stroma can be
seen in this example of chronic cutaneous lupus erythematosus. Original magnification
200

205
Figure 21.17 Immunofluorescent staining for IgM in a patient with chronic cutaneous
lupus erythematosus. A bright, green, granular band of staining highlights the epidermal
and follicular basement membrane zones. Slide courtesy of Kathleen David-Bajar, MD
Figure 21.18 Gray-scale rendition of Figure 21.17 identifies the epidermal basement
membrane zone (EP B Z) and the follicular basement membrane zone (F B Z)
CHAPTER 22
Brocqs alopecia (pseudopelade of Brocq)
and burnt out scarring alopecia
BROCQS ALOPECIA
The term pseudopelade of Brocq is a source of much confusion and fruitless
debate, and should be abandoned. Pseudopelade has been used in recent decades
to describe some patients with central, centrifugal scarring alopecia (CCSA), a
very different condition from that described by Dr Brocq. To avoid confusion,
we can refer to the entity described by Brocq as Brocqs alopecia. Brocqs
alopecia is not a distinct disease but a clinical pattern of scarring alopecia. It is an
end-stage or clinical variant of several other forms of scarring alopecia and a
diagnosis of exclusion. The same pattern of hair loss can be seen in burnt out
lichen planopilaris (LPP), discoid lupus erythematosus (DLE) and other forms of
cicatricial hair loss. If a definitive diagnosis of DLE, LPP, CCSA or another form
of scarring alopecia can be made based on clinical, histological or
immunofluorescent features, then the term Brocqs alopecia cannot be used. If a
primary form of Brocqs alopecia exists, it has yet to be convincingly described.
The Brocqs alopecia pattern of hair loss is very uncommon. The typical
patient is a Caucasian adult who is surprised to discover discrete, asymptomatic
areas of scalp hair loss. In some patients, the disease is slowly progressive, and
new areas of alopecia develop over a period of months to years. However, the
condition often worsens in spurts, with periods of activity followed by dormant
periods. This is distinctly different from the slow but steady disease progression
seen in forms of CCSA described in Chapter 18. Disease progression in Brocqs
alopecia eventually terminates spontaneously.
Unlike CCSA, Brocqs alopecia results in irregularly shaped and often widely
distributed and grouped bald patches on the scalp. Cases with exclusive crown or
vertex involvement may actually represent examples of burnt out CCSA.
The individual lesion is hypopigmented (porcelain white is the classic
description) and slightly depressed (atrophic). Lesions are often irregularly
shaped, as opposed to the round or oval patches usually seen in alopecia areata
and most cases of CCSA (Figure 22.1). The classic description of footprints in
the snow refers to dermal atrophy causing a slight depression below the
surrounding normal scalp. In fact, many cases of Brocqs alopecia do not
Figure 22.1 Typical lesion of Brocqs alopecia in a woman whose hairdresser discovered
the bald spot. There was no clinical evidence of active inflammation, and the histological
findings were those of burnt out scarring alopecia
demonstrate atrophy. Usually only mild erythema and slight perifollicular scaling
are present, and often there is no clinical evidence of inflammation. In fact, some
authors have argued that any inflammation excludes Brocqs alopecia from the
clinical differential diagnosis. Just as in other forms of scarring alopecia, a few
isolated hairs may remain within an otherwise smooth, shiny, denuded patch.
The histological findings of Brocqs alopecia have yet to be clearly defined.
The criteria established by Pinkus in 1978 are not correlated in any way with
clinical features. Thus, pseudopelade as described by Pinkus is a histological
and not a clinical entity. In most cases of Brocqs alopecia, the active lesion is
elusive, and the typical histological findings are those of a burnt out scarring
alopecia (see below).
The histological findings of pseudopelade more recently described apply to a
subset of CCSA rather than Brocqs alopecia. It would not be surprising to find
an occasional case of Brocqs alopecia demonstrating the typical histological
findings of CCSA. Brocqs alopecia is, after all, the end stage of several
different forms of scarring alopecia. A prospective study of Brocqs alopecia
with sound clinical correlation has yet to be performed.
BURNT OUT SCARRING ALOPECIA
All too often, pathologists must render the diagnosis of a burnt out or end
stage scarring alopecia. The histological term burnt out scarring alopecia, like
the clinical term Brocqs alopecia, does not indicate a specific disease but a
pattern common to several entities. There are two possible reasons for finding
this pattern. First, the patients disease may, in fact, have truly burnt out like an
old forest fire, with no further follicular destruction. More commonly, however,
the end stage pattern is the result of clinicians unfortunate choice of biopsy
sites. Frequently, bald or nearly bald areas are sampled, instead of spots where
numerous hairs are still present. The advancing border of a zone of scarring
alopecia is always a more productive site than a bald zone. Areas with subtle
BROCQS ALOPECIA AND BURNT OUT' SCARRING ALOPECIA 209
Figure 22.2 The paucity of terminal hairs, lack of inflammation and absence of sebaceous
glands are typical of a burnt out scarring alopecia. This particular example was taken
from a patient who proved to have central, centrifugal scarring alopecia (based on
additional specimens). Original magnification 40
Figure 22.3 Naked hair shaft surrounded by granulomatous inflammation and fibrosis.
findings such as perifollicular erythema or scaling prove more fruitful than

places showing the advanced findings of pustules, papules, extensive hair loss
or obliteration of follicular ostia. Just a few millimeters may separate a perfect
from a suboptimal biopsy site, but even experienced clinicians cannot see below
the surface of the skin. In patients with progressive hair loss, the diagnosis of burnt
out scarring alopecia should serve as an invitation for additional biopsy
specimens.
An end stage or burnt out scarring alopecia is characterized by: a decreased
total number of hairs, especially terminal hairs (Figure 22.2); loss of the
sebaceous glands; residual, naked hair shafts surrounded by mild,
granulomatous inflammation (Figure 22.3); follicular stelae without overlying
follicles; and cylindrical columns of connective tissue representing the sites of
former follicles (Figures 22.422.6).
Dense, superficial, perifollicular inflammation, with destruction of the
follicular epithelium (Figure 22.7; see also Figures 18.1718.20), may be
interpreted as a non-specific, late finding heralding impending burn out at the
Figure 22.4 Transverse section of columns of connective tissue that mark the sites of
former follicles (arrowhead). The absence of associated inflammation indicates that the
destructive process has truly burnt out, at least at the site chosen for biopsy. Original
magnification 100
biopsy site. However, this end stage histological finding indicates that the
patient has active, progressive disease.
Figure 22.5 Vertical section of a column of connective tissue, the site of a former follicle
(follicular scar). Original magnification 100
SUMMARY
Brocqs alopecia
Clinical correlation: usually in a Caucasian adult, who discovers discrete,
asymptomatic, hypopigmented, slightly depressed (atrophic) and irregularly
shaped bald patches affecting any portion of the scalp.
Histological findings: Brocqs alopecia represents the end stage of various
forms of scarring alopecia and usually shows features of a burnt out scarring
alopecia (see below). If typical histological findings of LPP, CCSA or other
types of scarring alopecia are found, the diagnosis of Brocqs alopecia can be
excluded.
Figure 22.6 Higher power view of the follicular scar shown in Figure 22.5. Original
magnification 200
Burnt out scarring alopecia

Clinical correlation: most often indicative of bald or nearly bald plaques in
patients with various forms of scarring alopecia. Biopsy site sampling error (and
sometimes disease resolution) is the most common explanation.
Decreased total number of hairs, especially terminal hairs

Loss of the sebaceous glands
Residual, naked hair shafts surrounded by mild, granulomatous
inflammation
Follicular stelae without overlying follicles
Cylindrical columns of connective tissue at the sites of former follicles
Figure 22.7 Dense, acute and chronic inflammation surrounds a residual hair shaft (lost
during processing). This histological pattern often corresponds to the clinical finding of
pustules or crusted papules. These are late and non-specific findings. Original
magnification 200
BIBLIOGRAPHY
Amato L, Mei S,Massi D.Gallerani I, Fabbri P. Cicatricial alopecia; a dermatopathologic
and immunopathologic study of 33 patients (pseudopelade of Brocq is not a specific
clinicopathologic entity). Int J Dermatol 2002; 41:815
Braun-Falco O, lmai S, Schmoeckel C, Steger O, Bergner T. Pseudopelade of Brocq.
Dermatologica 1986; 172:1823
Brocq L, Lenglet E,Ayrignac J. Recherches sur lalopcie atrophiante, varit
pseudopelade. Ann Dermatol Syphil (France) 1905;6:1 132, 97127, 20937
Dawber R. What is pseudopelade? Clin Exp Dermatol 1992; 17:3056
Nayar M, Schomberg K, Dawber RP, Millard PR. A clinicopathological study of scarring
alopecia. Br J Dermatol 1993; 128:5336
Pinkus H. Differential patterns of elastic fibers in scarring and non-scarring alopecias. J
Cutan Pathol 1978; 5:93104
Ronchese F. Pseudopelade. Arch Dermatol 1960; 82:33643 Silvers DN, Katz BE,Young
AW. Pseudopelade of Brocq is lichen planopilaris: report of four cases that support
this nosology. Cutis 1993; 51:99105
136:23542
Templeton SF,Solomon AR. Scarring alopecia: a classification based on microscopic
criteria. J Cutan Pathol 1994; 21:97109 Whiting DA. Cicatricial alopecia: clinicopathological findings and treatment. Clin Dermatol 2001; 19:211 -25
CHAPTER 23
Acne keloidalis (folliculitis keloidalis)
Often called acne keloidalis nuchae, this disorder typically affects young Black
men and occasionally young Black women. Acne keloidalis (AK) is at least ten
times more common in Blacks than in Caucasians and comprises nearly 0.5% of
all dermatological cases in the Black population. However, the condition can
occur in Caucasian men and on rare occasions in Caucasian women. It begins as
small, smooth, firm papules with occasional pustules on the occipital scalp and
posterior neck. In a minority of cases, lesions are more numerous on the vertex
and crown, and so it is best to use the term acne keloidalis without the modifier
nuchae. Initially hairs can be seen exiting the papules, but the hair shafts are
soon shed. With time, the papules resolve and leave small zones of alopecia
within a field of papular lesions. In many patients, the papules coalesce and form
firm, hairless, keloid-like protuberant plaques (hence the term keloidalis) that can
be painful and cosmetically disfiguring. Abscesses and sinuses exuding pus can
be present in advanced cases. Although AK may be asymptomatic, mild
symptoms of burning and itching are often present.
The cause of AK remains unclear. The notion that lesions of AK are caused by
ingrowing hairs, analogous to the situation in pseudofolliculitis barbae, has
been disproved. AK is frequently found in association with central, centrifugal
scarring alopecia (CCSA), suggesting a common or related pathogenesis
(Figures 23.123.4). Occasionally, the papular lesions and hair loss of AK extend
up onto the vertex of the scalp, producing a clinical overlap of AK and CCSA.
Most descriptions of the pathology of AK are based on late-stage, nodular
lesions. When early, papular lesions or samples of perilesional skin are studied,
the findings are those of a chronic, lymphocytic folliculitis. AK is a primary form
of scarring alopecia, and many of the histological findings closely resemble those
found in certain other forms of cicatricial alopecia. The most common findings,
in order of frequency found, are: perifollicular, chronic inflammation
(lymphocytic and plasmacytic), most intense at the level of the isthmus and
lower infundibulum (Figures 23.5 and 23.6); lamellar fibroplasia, most marked
at the level of the isthmus; complete disappearance of sebaceous glands
ACNE KELOIDALIS (FOLLICULITIS KELOIDALIS) 215
Figure 23.1 Typical acne keloidalis lesions on the nuchal region of a woman with typical
central, centrifugal scarring alopecia on the crown
Figure 23.2 Central, centrifugal scarring alopecia on the crown of the woman in
Figure 23.1
Figure 23.3 Acne keloidalis lesions on the nuchal region of a man with central,
centrifugal scarring alopecia on the vertex/ crown
associated with inflamed or destroyed follicles; thinning of the follicular

epithelium, especially at the level of the isthmus; polytrichia (several hairs
sharing a common, fused infundibulum; Figure 23.7); and total epithelial
destruction (superficial and deep) with residual naked hair fragments (Figures
23.823.12). Some of these retained shafts are slowly resorbed, resulting in a
Figure 23.4 Central, centrifugal scarring alopecia on the vertex/crown of the man in
Figure 23.3
focal bald spot. Others, however, can serve as a nidus for marked fibrosis,
persistent inflammation and bacterial superinfection. The resulting tissue
hypertrophy traps adjacent follicles, and eventually leads to the keloidal,
hypertrophic scarring seen in some patients with AK.
Even some specimens from normal-appearing perilesional skin may contain
true follicular scars, demon-strating subclinical disease. Special stains for
bacteria demonstrate relatively few organisms, suggesting that bacterial
overgrowth is not important in the pathogenesis of the disease.
Many of the histological features of AK are shared by CCSA. This overlap of
histological features suggests a common pathogenesis for AK and CCSA, a
notion that is supported by the frequent occurrence of both conditions in the
same patient. As mentioned above, clinical features sometimes overlap as well.
SUMMARY
Clinical correlation: small, smooth, firm follicular papules with occasional
pustules, eventually leading to partial hair loss; most common on the nuchal
Figure 23.5 Specimen taken from normal-appearing, perilesional skin in a patient with
typical acne keloidalis nuchae. Two follicles sharing a common infundibulum
demonstrate perifollicular lymphocytic inflammation, lamellar fibroplasia and loss of the
sebaceous glands. Two normal-appearing adjacent follicles (on the right side, also sharing
a fused infundibulum) are present for comparison. Original magnification 100
region (occipital scalp and posterior neck). With advanced disease, there are
coalescent papules forming firm, hairless, keloid-like protuberant plaques.
Perifollicular, chronic inflammation (lymphocytic and plasmacytic)

Perifollicular, lamellar fibroplasia
Complete disappearance of sebaceous glands associated with inflamed or
destroyed follicles
Thinning of the follicular epithelium, especially at the level of the isthmus
Eventually, total epithelial destruction, with residual naked hair fragments
BIBLIOGRAPHY
Dinehart S, Herzerg A, Kerns B, Pollack S. Acne keloidalis: a review. J Dermatol Surg
Oncol 1989; 15:642647
Dinehart SM, Tanner L, Mallory SB, Herzberg AJ. Acne keloidalis in women. Cutis
1989; 44:2502
Herzberg A, Dinehart S, Kerns B, Pollack S. Acne keloidalis. Transverse microscopy,
immunohistochemistry and electron microscopy. Am J Dermatopathol 1990; 12:
10921
Sperling L, Homoky C, Pratt L, Sau P. Acne keloidalis is a form of primary scarring
alopecia. Arch Dermatol 2000; 136: 47984
136:23542
Figure 23.6 Higher power view of the section shown in Figure 23.5. Original
magnification 200
Figure 23.7 In a specimen taken from a small papular lesion of acne keloidalis nuchae,
two follicles (sharing a fused infundibulum) are surrounded by dense, lymphocytic
Figure 23.8 Specimen taken from a papular lesion of acne keloidalis nuchae shows dense
perifollicular chronic inflammation, most intense at the level of the lower isthmus. The
epithelium is disrupted at this level, and such follicles are doomed to destruction. Original
magnification 40
Figure 23.9 Higher power view of the specimen in Figure 23.8. Original magnification
100
Figure 23.10 When the epithelium of follicles has been disrupted or destroyed, the
inflammatory infiltrate is often rich in plasma cells as well as lymphocytes. Original
magnification 400
Figure 23.11 Two follicles in a papular lesion of acne keloidalis nuchae, sectioned at the
level of the upper isthmus. The epithelium of one follicle has been completely destroyed
below the level of the isthmus, which would result in permanent hair loss. Original
magnification 200
Figure 23.12 Three hairs in a papular lesion of acne keloidalis nuchae, sectioned at the
level of the lower isthmus. Original magnification 200
CHAPTER 24
Dissecting cellulitis of the scalp
(perifolliculitis capitis abscedens et
suffodiens)
Dissecting cellulitis is an uncommon but distinctive disease. It most commonly

affects young adult men, especially Black men. Dissecting cellulitis is part of the
follicular occlusion triad that includes hidradenitis suppuritiva and acne
conglobata, but scalp disease often occurs alone.
Lesions begin as multiple, firm scalp nodules, most commonly on the crown,
vertex and upper occiput. The nodules rapidly develop into boggy, fluctuant,
oval and linear ridges that eventually discharge purulent material (Figure 24.1).
Lesions often interconnect, so that pressure on one fluctuant area may result in a
purulent discharge from perforations several centimeters away (Figure 24.2).
Despite massive, deep inflammation, there can be surprisingly little pain, and
patients often seek help because of hair loss and a foulsmelling discharge.
The disease waxes and wanes for years, but eventually leads to dense dermal
fibrosis, sinus tract formation, permanent alopecia and hypertrophic scarring.
Squamous cell carcinoma has rarely been reported to arise in the setting of longstanding disease.
The very earliest findings have seldom been described, probably because patients
first consult physicians after the disease is fairly well developed. Also, clinicians
are more likely to take biopsy specimens from nodular or cystic lesions that
represent more advanced, long-standing disease. In the authors experience, the
earliest change is moderately dense, perifollicular lymphocytic inflammation
affecting the lower half of the dermis and extending down into the fat (Figures
24.3 and 24.4). At this stage, numerous intact and seemingly undamaged follicles
are bathed in a sea of acute and chronic inflammation. Terminal anagen hairs are
reduced in number, because many have converted to the catagen/telogen phase
(Figure 24.5). Initially, lymphocytes dominate the infiltrate, but eventually
neutrophils become more numerous, especially in long-standing, fluctuant
lesions. Still later, plasma cells increase in number. Vascular proliferation
accompanies the infiltrate as the disease evolves, and the deep dermis and
subcutaneous fat begin to exhibit the histological findings of granulation tissue
DISSECTING CELLULITIS OF THE SCALP 225
Figure 24.1 Dissecting cellulitis in an African American man
Figure 24.2 Interconnecting, fluctuant nodules of dissecting cellulitis in a Caucasian man.

Photograph courtesy of Jeffrey Miller, MD
In most other forms of inflammatory, scarring alopecia, the sebaceous glands

are often the first structure to disappear. However, sebaceous glands remain
intact well into the course of dissecting cellulitis. This relative sparing of
sebaceous glands may be related to the depth of the infiltrate in the disease
The intense inflammation is associated with the conversion of anagen hairs
into catagen/telogen hairs, whose shafts are ultimately shed. Therefore, the hair
loss seen in the early stages of dissecting cellulitis is temporary. However, with
Figure 24.3 Early lesions of dissecting cellulitis. Inflammation is concentrated at the

level of the deep dermis/superficial fat, corresponding to the level of the terminal hair
bulbs. Note the paucity of terminal anagen hair bulbs and the intact sebaceous glands.
the passage of time, inflammation extends throughout the dermis and invades the
follicular epithelium, and there is subsequent epithelial injury and follicular
destruction. Repetitive injury to the follicles results in acneiform dilatation of the
infundibula, with perifollicular neutrophilic inflammation (Figure 24.10).
If fluctuant nodules and sinuses are sampled, large perifollicular and mid- to
deep dermal abscesses composed of neutrophils, lymphocytes and often
numerous plasma cells are seen. Eventually, chronic abscesses become lined
with squamous epithelium derived from the overlying epidermis, and true sinus
tracts are formed. As follicles are completely destroyed, inflammation subsides
and is replaced by dense fibrosis of the dermis and the superficial fat.
SUMMARY
Clinical correlation: young adults, usually male and often African American,
with boggy nodules and a purulent discharge on the scalp. Lesions are scattered,
but most are concentrated on the crown, vertex and upper occiput.
Figure 24.4 Another section showing early lesions of dissecting cellulitis (see
Figure 24.3). Original magnification 40
Figure 24.5 A terminal catagen hair bulb is surrounded, but not invaded, by a dense
lymphocytic infiltrate. Original magnification 400
Very early lesions are seldom evaluated, but may show moderately dense,
lymphocytic, perifollicular inflammation surrounding the lower half of the
follicle
Figure 24.6 In well-established dissecting cellulitis, the deep dermis and superficial fat
are replaced by a dense, mixed inflammatory infiltrate, edema and vascular proliferation.
Figure 24.7 Well-established dissecting cellulitis. Original magnification 400
Increase in catagen/telogen hairs

Sebaceous glands may persist well into the course of the disease
Fully developed, fluctuant lesions show perifollicular and mid- to deep
dermal abscesses composed of neutrophils, lymphocytes and often copious
plasma cells
Eventually, granulation tissue, epithelium-lined sinus tracts and fibrosis are
seen
BIBLIOGRAPHY
Benvenuto ME, Rebora A. Fluctuant nodules and alopecia of the scalp. Perifolliculitis
capitis abscedens et suffodiens. Arch Dermatol 1992; 128:111519
Herman A, David M, Pitlik S. Perifolliculitis capitis abscedens et suffodiens. Int J
Dermotol 1992; 31:746
136:23542
Stites PC, Boyd AS. Dissecting cellulitis in a white male: a case report and review of the
literature. Cutis 2001; 67:3740
Figure 24.8 Despite the loss of follicles and the severity of deep inflammation, sebaceous
glands persist well into the course of the disease. Original magnification 40
Figure 24.9 Dissecting cellulitis. Sebaceous glands are spared. Original magnification
100
Figure 24.10 Acneiform dilatation of the infundibulum. Original magnification 100
CHAPTER 25
Tufted folliculitis
The tufting seen in this pattern of hair disease is common to several forms of
scarring alopecia (Figure 25.1). It is not a specific disease, but an end stage of
several different conditions. In spite of this, tufted folliculitis continues to be
applied as a diagnostic term in the medical literature. Such usage is incorrect and
misleading.
Tufting occurs because the infundibular epithelium of damaged follicles often
heals with the formation of a large, common infundibulum (Figure 25.2). A zone
of fibrosis separates individual tufts. Another name for this phenomenon is
polytrichia. Although tufting is fairly common in cases of central, centrifugal
scarring alopecia, it can occasionally be seen in a wide variety of
Figure 25.1 Dramatic example of polytrichia (tufting) in a patient with central,

centrifugal scarring alopecia
other disorders, including folliculitis keloidalis, dissecting cellulitis and

inflammatory tinea capitis.
BIBLIOGRAPHY
Annessi G. Tufted folliculitis of the scalp: a distinctive clinicohistological variant of
folliculitis decalvans. Br J Dermatol 1998; 138:799805
Isomura I, Morita A,TamadaY. A case of tufted hair folliculitis. J Dermatol 2002; 29:
42730
233
Figure 25.2 A histological view of polytrichia (tufting). Whenever the upper halves of
adjacent follicles become inflamed and damaged, a large, common infundibulum may
form. Original magnification 100
Powell JJ, Dawber RP, Gatter K. Folliculitis decalvans including tufted folliculitis:
clinical, histological and therapeutic findings. Br J Dermatol 1999140:32833
136:23542
CHAPTER 26
Tinea capitis
Most cases of tinea capitis (fungal infection of scalp hair) seen in North America
are caused by Trichophyton tonsurans, a large-spore endothrix infection.
Microsporum canis (ectothrix) is also found occasionally. Different species may
be more prevalent in other parts of the world. The fungus invades and multiplies
within the hair shaft below the surface of the skin, causing hair fragility and
breakage. This results in bald spots with follicular ostia filled with keratinous
debris or black dots, the residua of infected, pigmented hair shafts
(Figure 26.1). Variable degrees of inflammation may be seen, ranging from none
(no erythema or scaling) to highly inflamed, purulent, edematous and crusted
plaques (kerion; Figure 26.2). Pustular lesions on the scalp should always raise
suspicion for tinea capitis. Tinea capitis almost always affects children, and
African American children seem to be especially prone to infection. Any
inflamed or scaly bald spot on the scalp of an African American child should be
considered to be tinea capitis unless proven otherwise. However, adults of all
races (but especially African American women) can also be affected. If treated
early, tinea capitis heals without scarring or hair loss. However, highly
inflammatory lesions or untreated lesions may eventuate in permanent hair loss.
Inflammatory tinea capitis is one of several causes of tufted folliculitis
(polytrichia).
The common denominator and pathognomonic finding in all cases of tinea
capitis is the presence of spores (and sometimes hyphae) within the hair shaft
(Figures 26.3 and 26.4). Only a few follicles within a specimen may demonstrate
this finding, so that transverse sectioning is the most reliable way to establish the
diagnosis. The histological degree of inflammation is highly variable. In many
cases, hairs packed with spores are almost free of perifollicular inflammation
(Figure 26.5). A superficial and/or deep perifollicular infiltrate rich in
neutrophils, eosinophils, lymphocytes and plasma cells may be present (Figures
26.626.9).
Exceptional cases of inflammatory tinea capitis resembling dissecting
cellulitis (Figure 26.10) have a deep, dense lymphocytic infiltrate that surrounds
TINEA CAPITIS 235
Figure 26.1 Nine-month-old African American baby with black dot tinea capitis caused
by Trichophyton tonsurans. Although there is extensive hair loss, clinical inflammation
(erythema, scaling) is not present
Figure 26.2 Highly inflammatory tinea capitis caused by Trichophyton tonsurans in a

Caucasian boy
hair bulbs and extends into the fat (Figures 26.1126.14). Suprisingly, although
clinical findings and degree of histological inflammation are quite dramatic,
infected follicles may be difficult to find. In these cases, fungal cultures may be
required to establish the diagnosis.
SUMMARY
Clinical correlation: patients are most often children with bald, scaly,
erythematous patches on the scalp. Dark and widened follicular ostia (black
dots) may be present. The clinical manifestations of inflammation are highly
variable and range from mild scaling without erythema to intense erythema,
induration, pustules and a purulent discharge.
Spores (and sometimes hyphae) within hair shafts are a diagnostic feature, but
not every follicle in a specimen may be involved
The amount of perifollicular inflammation is highly variable
Figure 26.3 Transverse section of follicle infected with fungal spores.An affected shaft
(right side) is adjacent to one that is totally spared. Original magnification 400
A superficial and/or deep perifollicular infiltrate rich in neutrophils,

eosinophils, lymphocytes and plasma cells may be present
BIBLIOGRAPHY
Aly R. Ecology, epidemiology and diagnosis of tinea capitis. Pediatr Infect Dis J 1999;
18:1805
Frieden IJ, Howard R. Tinea capitis: epidemiology, diagnosis, treatment, and control. J
Am Acad Dermatol 1994; 31:S426
Gianni C, Betti R, Perotta E, Crosti C. Tinea capitis in adults. Mycoses 1995; 38:32931
Sperling LC. Inflammatory tinea capitis (kerion) mimicking dissecting cellulitis:
occurrence in 2 adolescents. Int J Dermatol 1991; 30:1902
TINEA CAPITIS 237
Figure 26.4 Vertical section of follicle infected with fungal spores. Original
magnification 400
Figure 26.5 Same follicles as in Figure 26.3. Although one hair shaft is filled with spores,
perifollicular inflammation is scanty. Original magnification 200
TINEA CAPITIS 239
Figure 26.6 An example of highly inflammatory tinea capitis. Such cases are often
associated with pustules or a purulent discharge and crusting. Original magnification 40
Figure 26.7 Perifollicular infiltrate containing numerous eosinophils as well as

lymphocytes. Original magnification 400
Figure 26.8 Inflammation often extends into the follicular wall, and in some cases
eventuates in follicular destruction. Original magnification 400
TINEA CAPITIS 241
Figure 26.9 The deep portion of the infiltrate seen in tinea capitis is predominantly
composed of lymphocytes and plasma cells. Original magnification 400
Figure 26.10 Tinea capitis resembling dissecting cellulitis in an adolescent boy. A culture
identified the causative organism as Trichophyton tonsurans
Figure 26.11 Tinea capitis resembling dissecting cellulitis (same adolescent boy as in
Figure 26.10). Inflammation is intense but quite deep, predominantly involving the
superficial fat. Original magnification 40
Figure 26.12 Same patient as in Figure 26.11. Original magnification 200
Figure 26.13 Hairs adjacent to the zone of inflammation may be converted to the catagen/
telogen phase. Original magnification100
TINEA CAPITIS 243
Figure 26.14 Even anagen hairs may remain unaffected although surrounded by a sea of
CHAPTER 27
Aplasia cutis congenita of the scalp
Aplasia cutis congenita (ACC) is the congenital absence of skin. The scalp is by
far the most common site for solitary lesions of ACC. Occasionally two or even
three lesions of ACC can occur together on the scalp. Lesions are often located
near the hair whorl on the vertex of the scalp, and can be various shapes and
sizes (0.510 cm). At the time of birth the defects may be deeply ulcerated,
superficially eroded or completely healed but scarred (Figure 27.1).
Biopsy specimens from patients with ACC are often obtained well after birth,
when the lesions are excised for cosmetic reasons. The epidermis usually
demonstrates some flattening of the rete ridges. A few
Figure 27.1 Solitary lesion of aplasia cutis congenita adjacent to the scalp whorl of a
young boy. The child had been born with a friable wound on the scalp that healed with
this scarred appearance
residual hair follicles may remain stranded in a dermis that is otherwise devoid
of adnexal structures, including follicles and sweat glands. When the central
portion of the lesion is compared with the surrounding normal scalp skin, the
dermis usually appears thickened, because the superficial subcutaneous fat has
been replaced by collagenous tissue (Figures 27.227.4). However, in some
instances, the dermis is relatively thinned.
APLASIA CUTIS CONGENITA OF THE SCALP 245
Figure 27.2 Dermal thickening and loss of follicles is evident in the central portion (right
side) of this lesion of aplasia cutis congenita as compared with the border (left side).
Figure 27.3 Flattening of the rete ridges is evident in the central portion of this lesion of
aplasia cutis congenita (right side) as compared with the border (left side). Loss of follicles
and thickening of the dermis are also seen. Original magnification 40
Figure 27.4 Same section as in Figure 27.3. Original magnification100
Collagen bundles are usually thickened and sclerotic in appearance, and are
often oriented in bundles parallel to the skin surface, as would be expected in a
well-healed scar (Figures 27.5 and 27.6). Occasionally, however, the thickened
dermal collagen appears deceptively normal, because of the random orientation
of collagen bundles. However, even in these cases, adnexal structures are absent
Figure 27.5 Sclerotic, parallel collagen bundles in a lesion of aplasia cutis congenita.
Figure 27.6 Same section as in Figure 27.5. Original magnification 100
or rare (Figures 27.7 and 27.8). Inflammation is not seen in completely healed
lesions of ACC.
APLASIA CUTIS CONGENITA OF THE SCALP 247
Figure 27.7 In this lesion of aplasia cutis congenita, the dermis is relatively thinned.The
loose, random orientation of collagen bundles looks normal, but adnexal structures are
sparse. Original magnification 40
Figure 27.8 The same section as in Figure 27.7. Original magnification100
SUMMARY
Clinical correlation: a single (rarely multiple) hairless plaque, most often located
near the hair whorl on the vertex of the scalp. Lesions are present at birth, and
can be of various shapes and sizes. At birth, the defects may be deeply ulcerated,
superficially eroded or completely healed but scarred. Most lesions are excised
well after birth, when they are completely healed.
Flattening of the rete ridges

Thickening of the dermis with replacement of fat by collagen
Absence of most or all adnexal structures including follicles and sweat glands
Thickening, sclerosis and parallel orientation of dermal collagen fibers
BIBLIOGRAPHY
Deeken JH, Caplan RM. Aplasia cutis congenita. Arch Dermatol 1970; 102:3869
Frieden IJ. Aplasia cutis congenita: a clinical review and proposal for classification. J Am
Acad Dermatol 1986; 14:64660
Itin P, Pletscher M. Familial aplasia cutis congenita of the scalp without other defects in 6
members of three successive generations. Dermatologica 1988; 177:1235
Kenner JR, Sperling LC. Pathological case of the month. Temporal triangular alopecia
and aplasia cutis congenita. Arch Pediatr Adolesc Med 1998; 152:12412
Kosnik EJ, Sayers MP. Congenital scalp defects: aplasia cutis congenita. J Neurosurg
1975; 42:326
Munkvad JM, Nielsen AO, Asmussen T. Aplasia cutis congenita. A follow-up evaluation
after 25 years. Arch Dermatol 1981; 17:2323
Sargent LA Aplasia cutis congenita of the scalp. J Pediatr Surg 1990; 25:121113
Stephan MJ, Smith DW, Ponzi JW, Alden ER. Origin of scalp vertex aplasia cutis. J
Pediatr 1982; 101:8503
CHAPTER 28
Overview of hair shaft disorders
A detailed review of hair shaft abnormalities is beyond the scope of this text.
Several excellent reviews of hair shaft disorders are available and are listed at the
end of the appropriate following sections. However, pathologists,
dermatopathologists and dermatologists are sometimes called upon to identify a
hair shaft disorder from a submitted sample of hair. This section will focus on
describing the morphological features of shaft disorders as seen by light
microscopy.
TRICHORRHEXIS NODOSA
The basic cause of trichorrhexis nodosa is trauma to the hair shafts, but any
inherent weakness of the shaft may result in this defect. All the various forms of
weathering (grooming, washing, styling, etc.) can cause or worsen the disorder.
Examples of physical trauma include excessive brushing, the application of heat,
hair pulling in trichotillomania and scratching due to pruritic scalp disorders.
Examples of chemical trauma include permanent straightening (relaxing;
Figure 28.1), permanent waving, dyeing and shampooing. Clinically,
trichorrhexis nodosa may appear as small, white or gray specks on the hair shafts.
Affected hairs are susceptible to fracture, which can result in patchy or diffuse
alopecia, depending on the extent of involvement. Although scalp hair is usually
affected, trichorrhexis nodosa can be found on pubic hair and other hairy areas of
the body.
The nodes of trichorrhexis nodosa represent foci of frayed cortical fibers that
bulge out through a ruptured cuticle. Scanning electron microscopy has shown
that the earliest change is a focal loss of cuticular cells, which eventually results
in hair fiber separation and fracture. Each node then takes on the appearance of
two paintbrushes whose bristles have been pushed together (Figures 28.2 and
28.3). Each bristle represents a cornified cortical cell, which can separate from
adjacent cells once the binding function of the cuticle is impaired.
Trichorrhexis nodosa is often found in association with other types of hair
shaft abnormalities caused by weathering or inherited hair fragility. Therefore,
trichoclasis (greenstick fractures), trichoptilosis (split ends) and trichoschisis
Figure 28.1 Hair loss in an African American woman caused by chemical relaxers.
Longer hairs along the margins of the bald spot showed dramatic trichorrhexis nodosa
of the proximal shafts. Hair loss was due to fractures of the damaged shafts
(see below) are often found in hairs from the same patient or even the same shaft
(Figure 28.4).
BIBLIOGRAPHY
Caserio RJ. Diagnostic techniques for hair disorders. Part I: Microscopic examination of
the hair shaft. Cutis 1987; 40: 26570
Dawber RP. An update of hair shaft disorders. Dermatol Clin 1996; 14:75372
Rogers M. Hair shaft abnormalities: Part 1. Australas J Dermatol 1995; 36:17984
Whiting DA. Structural abnormalities of the hair shaft. J Am Acod Dermotol 1987; 16:
125
TRICHOSCHISIS
The term trichoschisis is used for a clean, transverse fracture across the hair
shaft through cuticle and cortex. A localized absence of cuticle cells can be
found at the site of the fracture. Although trichoschisls is occasionally found in
normal hair, it usually occurs in the setting of trichothiodystrophy (see below).
OVERVIEW OF HAIR SHAFT DISORDERS 251
Figure 28.2 Focal loss of the hair cuticle results in cortical fiber separation and the fragile
nodes of trichorrhexis nodosa
Figure 28.3 Fragile node of trichorrhexis nodosa
Figure 28.4 Trichoclasis (greenstick fracture of hair) and trichorrhexis nodosa are often
found in the same weathered shaft
TRICHOTHIODYSTROPHY
Patients with trichothiodystrophy have congenitally brittle hair with low sulfur
content. This hair defect serves as the common denominator for patients with
neuroectodermal abnormalities and mutations in the xeroderma pigmentosum
XP-B and XP-D helicase subunits of the dual functional DNA repair/basal
transcription factor TFIIH. Depending on the precise mutation, patients may
Figure 28.5 Trichoschisis in a patient with trichothiodystrophy. The sharply defined

transverse fracture results in hair fragility and fracture
Figure 28.6 Ribbon-like flattening and twisting of hairs in a patient with

trichothiodystrophy
have some or all of the following clinical manifestations: photosensitivity,

ichthyosis, brittle hair, impaired intellect, decreased fertility, short stature and a
wide variety of other abnormalities. The 2001 review by Itin, Sarasin and
Pittelkow is particularly useful.
Hair from patients with trichothiodystrophy demon-strates several
abnormalities that are visible with light microscopy. The first is trichoschisis, as
described above, which accounts for the brittleness of the hair (Figure 28.5).
Hair shafts may be focally flattened and ribbon-like (Figures 28.6 and 28.7). One
prominent and consistent finding is an alternating light and dark banding seen
with polarized light (Figures 28.8 and 28.9). The hair is placed between
polarizing filters, and the banding is most evident when the filters are rotated into
the crossed or extinguished position (background is dark). Banding can be
transverse or diagonal, and can be reversed (i.e., light becomes dark) by rotating
one of the filters about 45. This banding may be due to the undulating nature of
cortical fibers found in trichothiodystrophy (as seen in Figures 28.5 and 28.9).
Figure 28.7 Flattened hairs in a patient with trichothiodystrophy
Figure 28.8 Alternating light and dark banding (tiger tail phenomenon) in a patient with
trichothiodystrophy. A polarized hair with the filters in the crossed position is shown
here
Figure 28.9 The same shaft as in Figure 28.8, without filters in place
BIBLIOGRAPHY
Cleaver JE, Thompson LH, Richardson AS, States JC. A summary of mutations in the UVsensitive disorders: xeroderma pigmentosum, Cockayne syndrome, and
trichothiodystrophy. Hum Mutat 1999; 14:922
Figure 28.10 Nethertons syndrome. The distal portion of this hair shaft (left side) has
sunken into the proximal portion to create a node of trichorrhexis invaginata
Coin F, Marinoni JC, Rodolfo C, Fribourg S, Pedrini AM, Egly JM. Mutations in the XPD
helicase gene result in XP and TTD phenotypes, preventing interaction between XPD
and the p44 subunit of TFIIH. Nature Genet 1998; 20:1848
Dawber RP. An update of hair shaft disorders. Dermatol Clin 1996; 14:75372
Itin PH, Sarasin A, Pittelkow MR.Trichothiodystrophy: update on the sulfur-deficient
brittle hair syndromes. J Am Acod Dermatol 2001; 44:891920
Price VH. Trichothiodystrophy: update. Pediatr Dermatol 1992; 9:36970
TRICHORRHEXIS INVAGINATA
This rare, congenital hair shaft abnormality is seen in Nethertons syndrome, the
combination of short, brittle hair and an ichthyosiform erythroderma (especially
ichthyosis linearis circumflexa). Atopic dermatitis is also found in the majority
of patients. The defective gene in Nethertons syndrome is SPINK5, which
encodes a serine protease inhibitor.
Also called bamboo hair, trichorrhexis invaginata appears as multiple small
swellings spaced along the shaft at irregular intervals. Each swelling consists of a
cup-like expansion of the proximal hair cortex that surrounds a rounded distal
fragment, giving the defect the appearance of a ball-and-socket joint
(Figure 28.10). It appears as if the distal segment has intussuscepted down into
the proximal segment. These nodes are extremely fragile and susceptible to
fracture (Figures 28.11 and 28.12), and consequently the hair of affected persons
is short, thin and friable.
BIBLIOGRAPHY
Bitoun E, Chavanas S, Irvine AD, et al. Netherton syndrome: disease expression and
spectrum of SPINK5 mutations in 21 families. J Invest Dermatol 2002; 118:35261
Dawber RP. An update of hair shaft disorders. Dermotol Clin 1996; 14:75372
Whiting DA. Structural abnormalities of the hair shaft. J Am Acod Dermotol 1987; 16:
125
Figure 28.11 A node of trichorrhexis invaginata before fracture
Figure 28.12 A node of trichorrhexis invaginata after fracture
PILI ANNULATI
Also called ringed hair, pili annulati is characterized clinically by alternating
light and dark bands of color along the hair shafts. The colors are reversed when
the hairs are viewed by light microscopy. The banded appearance is obvious only
in blond or lightly pigmented hair, which often has a sandy appearance. The
condition may be present at birth or appear during infancy. Hair growth is
normal and in the majority of cases the hair is strong and sound, but there may be
some degree of shaft fragility. Trichorrhexis nodosa-like fractures may be
produced in the dark bands. There are no other associated abnormalities and
treatment is not required. The condition appears to be caused by a defect in hair
cornification.
The cortex of the abnormal bands contains zones of air-filled spaces
(Figure 28.13), between cortical fibers and within cortical cells. Medullary cells
are not involved in the process. The air-filled spaces can be confined to the
central portion of the shaft, or may involve the full thickness with associated
cuticle disruption.
Pili annulati has been associated with alopecia areata on more than one
occasion. It is not known whether or not this is pure coincidence.
BIBLIOGRAPHY
Dini G, Casigliani R, Rindi L, Grappone C, Melli MC, Lotti T.Pili annulati. Optical and
scanning electron microscopic studies. Int J Dermatol 1988;27:2567
Gummer CL, Dawber RP. Pili annulati: electron histochemical studies on affected hairs.
Br J Dermatol 1981; 105:3039
Ito M, Hashimoto K, Sakamoto F, Sato Y, Voorhees JJ. Pathogenesis of pili annulati.
Arch Dermatol Res 1988; 280:30818
Moffitt DL, Lear JT, de Berker DA, Peachey RD. Pili annulati coincident with alopecia
areata. Pediatr Dermatol 1998; 15:2713
Price VH,Thomas RS,Jones FT. Pili annulati. Optical and electron microscopic studies.
Arch Dermatol 1968; 98:6407
Smith SR, Kirkpatrick RC, Kerr JH, Mezebish D.Alopecia areata in a patient with pili
annulati. J Am Acad Dermatol 1995; 32:81618
BUBBLE HAIR
This distinctive hair shaft abnormality is usually seen in young women with a
localized area of uneven, fragile hairs. The involved hair is straighter and stiffer
than normal. Light microscopy has demonstrated that the hair shafts contain
large, irregularly spaced bubbles that expand and thin the hair cortex
(Figure 28.14). Hair fractures occur at the site of larger bubbles.
The problem is caused by traumatic hair care techniques involving heat, as
from a malfunctioning hair dryer. Once the damaged hair is trimmed, the
condition resolves completely with gentle hair styling.
BIBLIOGRAPHY
Detwiler SP, Carson JL,Woosley JT, Gambling TM, Briggaman RA. Bubble hair. Case
caused by an overheating hair dryer and reproducibility in normal hair with heat. J
Am Acad Dermatol 1994; 30:5460
Elston DM, Bergfeld WF, Whiting DA, et al. Bubble hair. J Cutan Pathol 1992; 19:
4394
Gummer CL Bubble hair: a cosmetic abnormality caused by brief, focal heating of damp
hair fibres. Br J Dermatol 1994; 131:9013
MONILETHRIX
Patients with monilethrix (beaded hair) have extremely brittle, beaded hairs
that emerge from keratotic, follicular papules. Hair shafts rarely grow more than
23 cm. The hairs fracture easily, usually resulting in severe alopecia. The
course is variable and seasonal, and some patients may show improvement in
adult life, while others seem to worsen. The condition usually appears in early
childhood, predominantly on the occiput and nape, but it can affect the entire
Figure 28.15 In monilethrix, the nodes correspond to the normal caliber of the hair and
the defective portion resides in the constrictions
scalp. Occasionally the child is born bald, with beaded hairs appearing several
months or years later. Facial and body hair are also involved in severe cases.
Monilethrix is usually inherited as an autosomal dominant trait with high
penetrance but variable expressivity. Recessive phenotypes have also been
described, as have sporadic cases. Mutations in two of the 11 known hair
keratins have been associated with monilethrix. Mutations in the hHb6 gene are
most common, but mutations in other genes (e.g., hHb1) can lead to the disease.
Hair shafts in patients with monilethrix show characteristic, evenly spaced,
elliptical nodes that are 0.71 mm apart (Figure 28.15). The intervals between
nodes will vary in different hairs from the same patient. Not every hair follicle is
affected in a synchronized fashion. The segments of hair shaft between nodes are
non-medullated, tapered constrictions. Imbricated cuticular scales are present on
the nodes, whereas the internodes show abnormal longitudinal ridging and often
absent scales. Scanning electron microscopy has demonstrated that the nodes
correspond to the normal caliber of the hair and that the defective portion resides
in the constrictions.
The hair roots have an architecture that conforms to the shaft abnormality,
with alternating constrictions, so that the hair is deformed as it is being
produced. Matrix cells destined to become cortical cells are particularly affected.
This seems to result in a decrease in number of cortical cells and thinning of the
hair shaft.
BIBLIOGRAPHY
Dawber RR An update of hair shaft disorders. Dermotol Clin 1996; 14:75372
Korge BP, Healy E, Munro CS, et al. A mutational hotspot in the 2B domain of human hair
basic keratin 6 (hHb6) in monilethrix patients. J Invest Dermotol 1998; 111:8969
Whiting DA. Structural abnormalities of the hair shaft. J Am Acad Dermotol 1987; 16:
125
Figure 28.16 Pili torti

Winter H, Rogers MA, Gebhardt M, et al. A new mutation in the type II hair cortex
keratin hHb1 involved in the inherited hair disorder monilethrix. Hum Genet 1997;
101:1659
PILI TORTI
Pili torti is the most misdiagnosed structural hair shaft defect, and it is often
confused with monilethrix when studied with light microscopy. Hairs in pili torti
are flattened and twisted on their longitudinal axes (Figures 28.16 and 28.17).
Each twist may be 90, 180, or up to 360. Typically, runs of four or five
twists are found at irregular intervals along the hair shaft. Involved hairs are
brittle, break off easily, do not achieve normal length and often have a spangled
or beaded appearance. The hairs are fragile and usually fracture within the
twists. The fractured distal tip often shows longitudinal fraying (trichoptilosis).
The hair follicles show no histological abnormalities other than some curvature
and twisting. Although it can be present at birth or emerge after puberty, pili torti
classically appears in early childhood when normal scalp hairs are replaced by
brittle, spangled hairs, especially in the occipital and temporal regions. The
spangled appearance is due to unequal reflection of light from the twisted
surface. The eye-brows and eyelashes may also be involved. There is a variable
degree of hair fragility ranging from patchy alopecia with coarse stubble to hairs
of 5 cm or more. Pili torti may improve after puberty or may persist throughout
life.
Pili torti is also found in various syndromes, such as Menkes kinky hair
disease, Bjornstad syndrome and Rapp-Hodgkin ectodermal dysplasia. The
numerous other distinctive features of these syndromes allow for proper
diagnosis, with pili torti offering an additional clue.
Figure 28.17 Scanning electron micrograph of a shaft showing pili torti
BIBLIOGRAPHY
Dawber RR An update of hair shaft disorders. Dermatol Clin 1996; 14:75372
Richards KA, Mancini AJ. Three members of a family with pili torti and sensorineural
hearing loss: the Bjornstad syndrome. J Am Acad Dermatol 2002; 46:3013
Whiting DA. Structural abnormalities of the hair shaft. J Am Acad Dermatol 1987; 16:
125
PILI MULTIGEMINI
This condition is typically found in the beard area, especially along the jaw.
Anywhere from two to eight hair matrices, each with its own papilla and separate
inner root sheath (Figure 28.18), form clusters of shafts that emerge from a
single follicular canal. Surrounding the cluster of hair bulbs is a common outer
root sheath that separates to invest each ascending hair shaft (Figures 28.19 and
28.20).
The shafts have various shapes in cross-section (flat, ovoid, triangular or
grooved), which probably results from the pressure between hairs in the same
follicle (Figure 28.21). Usually the condition is totally benign, but it may be
associated with perifollicular erythema resembling folliculitis. There is no
specific treatment for pili multigemini, which tends to be persistent. The
abnormal hairs will simply regrow after plucking.
BIBLIOGRAPHY
Cambiaghi S, Barbareschi M, Cambiaghi G, Caputo R. Scanning electron microscopy in
the diagnosis of pili multigemini. Acta Derm Venereol 1995; 75:1701
Mehregan AH.Thompson WS. Pili multigemini. Report of a case in association with
cleidocranial dysostosis. Br J Dermatol 1979; 100:31522
Pinkus H. Multiple hairs (Flemming-Giovannini): report of two cases of pili multigemini
and discussion of some other anomalies of the pilary complex. J Invest Dermatol
1951; 17:291 -301
UNCOMBABLE HAIR SYNDROME (PILITRIANGULI

ET CANALICULI; ORSPUN GLASS HAIR)
This condition was first described in 1973 as cheveux incoiffables (unstylable
hair). It has also been termed spun glass hair and pili trianguli et canaliculi.
Many familial cases of uncombable hair have been reported, and in those
instances an autosomal dominant pattern of inheritance appeared most likely.
The typical clinical picture includes onset in infancy or early childhood; blonde
to light brown hair; dry, frizzy and spangled hair texture; and slow to normal
growth rate. The hair is disorderly, stands out from the scalp, and cannot be
combed flat. Some spontaneous improvement is often noted later in childhood.
261
Figure 28.18 Forcibly plucked hair from a follicle demonstrating pili multigemini. A
syncytium of outer root sheath envelops several separate matrices, each producing its own
shaft
The hair shafts in uncombable hair are usually triangular in cross-section, but
can be kidney-shaped, flat, or irregular. Most of the hair shafts will demonstrate
the irregular, triangular shape. Longitudinal grooves running along the entire
shaft are common, hence the name pili trianguli et canaliculi. Although grooving
of a few hair shafts can be found on the normal scalp, in the uncombable hair
syndrome at least 50% of hair shafts demonstrate this abnormality. Grooves can
often be seen with the light microscope (Figure 28.22), although they are best
visualized with the scanning electron microscope (Figure 28.23). Scalp biopsy
reveals that the inner root sheath has the same configuration as the shaft.
BIBLIOGRAPHY
Dupre A, Bonafe JL, Litoux F, Victor M. Uncombable hair syndrome. Pili trianguli et
canaliculi. Ann Dermatol Venereol 1978; 105:62730
Hicks J, Metry DW, Barrish J, Levy M. Uncombable hair (cheveux incoiffables, pili
trianguli et canaliculi) syndrome: brief review and role of scanning electron
microscopy in diagnosis. Ultrastruct Pathol 2001; 25:99103
262
Figure 28.19 Vertical section through the bulb of a follicle demonstrating pili multigemini.
A common outer root sheath invests the clustered sibling hairs
McCullum N, Sperling LC, Vidmar D. The uncombable hair syndrome. Cutis 1990; 46:
47983
TAPERED HAIRS (PENCIL POINT HAIRS)

Tapered hairs that can be easily pulled from the scalp are always a pathological
finding. Tapered hairs are found in all forms of anagen arrest. Anagen arrest is a
pattern of hair loss caused by a sudden insult to the metabolic machinery of the
hair follicle. The classic form of anagen arrest is seen when patients receive
radiotherapy or systemic chemotherapy for the treatment of malignancy. The hair
matrix is very sensitive to the toxic effects of X-irradiation and chemotherapy.
Affected follicles produce shafts that become progressively smaller in volume and
cross-sectional dimension. These hairs quickly taper down to a point, resulting in
an extremely fragile constriction. Hair shafts easily fracture at the constrictions,
and pencil point hairs fall from the patients scalp in great numbers
(Figure 28.24).
Several diseases cause hair loss with the features of an anagen arrest. Severe,
rapidly progressive alopecia areata (e.g., alopecia totalis in evolution) has a similar
effect on the metabolic machinery of hair follicles, and tapered hairs are often seen
263
Figure 28.20 Transverse section through the bulb of a follicle demonstrating pili
multigemini. There are several sub-papillae, each with its own matrix and inner root
sheath
Figure 28.21 Transverse section through the infundibulum. The clustered shafts have
angulated, bizarre shapes
(Figure 28.25). When patients with systemic lupus erythematosus or secondary

syphilis experience rapid hair loss, it sometimes has features of an anagen arrest.
PERIPILAR CASTS (PSEUDONITS, HAIR CASTS)
Kligman and Brunner described this abnormality independently in 1957.
Peripilar casts are often referred to as hair casts, although the latter designation
is imprecise. They are tubular masses of amorphous material that are perforated
centrally by the hair shaft. Hair casts are conical proximally, and their distal end
may taper or in larger casts may expand into a funnel shape. Some casts conform
to the shape of the follicular canal and infundibulum. True (classic) peripilar
keratin casts are commonly composed of cornified external root sheath
(Figure 28.26), rarely composed of internal root sheath, and sometimes
composed of both external and internal root sheaths. These types can be
distinguished by staining with 4-dimethylaminocinnamaldehyde, which stains
the inner root sheath a reddish color, or with toluidine blue, which stains the inner
root sheath an intense blue (Figure 28.27).
264
Figure 28.22 The prominent grooving seen in the uncombable hair syndrome is visible
even with light microscopy
Figure 28.23 The grooving seen in the uncombable hair syndrome is best visualized
with scanning electron microscopy
Figure 28.24 Gently pulling on the hair was sufficient to remove numerous pencil point
hairs from a patient receiving systemic chemotherapy for a malignancy
BIBLIOGRAPHY
Brunner MJ, Facq LM. A pseudoparasite of the scalp hair. Arch Dermatol 1957; 75:583
Kligman AM. Hair casts. Arch Dermatol 1957; 75:50911
Scott MJ, Roenigk HH Jr. Hair casts: classification, staining characteristics, and
differential diagnosis. J Am Acad Dermatol 1983; 8:2732
265
Figure 28.25 A tapered hair gently pulled from the scalp of a patient with rapidly worsening
alopecia areata
Figure 28.26 A peripilar cast composed of infundibular keratin. This is the most common
kind of hair cast
266
Figure 28.27 Peripilar casts composed of distal fragments of inner root sheath. These casts
stain a dark blue with toluidine blue
Index
acne conglobata 125

acne keloidalis 119123
classification of alopecia and 26
inflammation in 31
premature desquamation of root sheath
in 32
acquisition of hair specimens 15
African American hair
acne keloidalis in 119
central centrifugal scarring alopecia in
91
cf. Caucasian 21
normal scalp 22
traction alopecia and braiding 51
alopecia
androgenetic 28, 3742
biphasic 25
Brocqs 115118
burnt-out scarring 116
central centrifugal scarring 26, 9199
cicatricial cf. non-cicatricial 25
diffuse cf. patchy 33
end-stage 116
frontal fibrosing 26, 107
inflammation in 31
non-scarring in systemic lupus
erythematosus 8386
postoperative 5557
catagen/telogen proportion in 30
pressure-induced, trichomalacia in 32
secondary 25, 26
senescent 3536
syphilitic 7983
temporal triangular 29, 5961
alopecia areata 6377
acute 65, 66
apoptosis in 66
cf. syphilitic alopecia 80
chronic 70, 71
exclamation mark hairs in 64
follicle density in 28
follicular dropout with intact sebaceous
gland 32
hair density and 29
hair loss patterns
circumscribed 63
diffuse 63
partial 63
reticular 63
inflammation in 30, 68
miniaturization in 71
mononuclear cell inflammatory
infiltrate 65
nanogen hairs in 71, 72, 73, 74
of beard area 63
pencil point hairs 6
subacute 68
suprabulbar zone in 67
trichomalacia in 32
alopecia totalis, stela in 77
alopecia totalis in evolution 63, 64, 65
anagen arrest 69, 149
anagen effluvium 69
anagen hair 1
African American 6
anatomy of 2
forcibly plucked 11
infundibulum of 4, 5
isthmus of 3
loose 87
newly growing 10
267
pull/pluck findings 10
suprabulbar zone 3
terminal type 2
anatomy
anagen hair 2
catagen hair 4
follicular in trichotillomania 47
normal 113
telogen hair 5
androgenetic alopecia 3742
cf. central centrifugal scarring alopecia
92
early stage appears as telogen effluvium
43
gland 32
hair density and 28, 29
histological findings in 37
pattern of hair loss in 34
typical features of 37, 41
antibiotics, use in central centrifugal
scarring alopecia 93
anticoagulants 43
anticonvulsants 43
antithyroid drugs 43
aplasia cutis congenita of the scalp 137
139
apoptosis
in alopecia areata 66
in catagen hair 4
architecture, normal 113
arrector pili, insertion of 3, 5
axillary hair loss 101
-blockers 43
bacteria, staphylococci in central
centrifugal scarring alopecia 98
bamboo hair 144
beaded hair 146
beard
alopecia areata in 63
pili multigemini in 147
biopsy
Caucasian cf. African 21
checklist for description of 19
technique for taking 15
template for hair biopsy report 23
Bjornstad syndrome 147

blank spots 20
braiding, traction alopecia and 51
Brocqs alopecia 101, 109, 115118
Brocqs pseudopelade, see Brocqs
alopecia
bubble hair 145, 146
bulb
early telogen hair 9
late telogen hair 9
of catagen hair 7
bulge zone 3, 5, 6
burnt-out scarring alopecia 116
burnt-out traction alopecia 51
C3, granular deposits of 111
catagen hair 1
anatomy of 4
bulb of 6
forcibly plucked 12
increased proportion 29
lower half 7
numbers in trichotillomania 48
percentage of as diagnostic feature 21
suprabulbar zone 7
Caucasian hair
cf. African American 21
normal scalp 22
CD3+ cells in alopecia areata 66
cellulitis
dissecting 125129
inflammation in 31
central centrifugal scarring alopecia 9199
cf. acne keloidalis 119
cf. lichen planopilaris 102
polytrichia in 131
chemicals (hair relaxers)
central centrifugal scarring alopecia
and 91
trichorrhexis nodosa and 141
chemotherapy, pencil point hairs 6
cheveux incoiffables 148
INDEX 269
chronic cutaneous lupus erythematosus 26,

31, 109114
end-stage 110
inflammation in 31
cicatricial alopecia
cf. non-cicatricial 25
classification of 25
follicular dropout with loss of
sebaceous gland 32
Civatte bodies 103, 111
classification
of cicatricial alopecia 25
of hair disease 2526
clefting as an artifact 87, 89, 105, 111, 113
clinical findings
in acne keloidalis 122
in androgenetic alopecia 42
in aplasia cutis congenita of the scalp
139
in Brocqs alopecia 118
in burnt-out scarring alopecia 116, 118
in central centrifugal scarring alopecia
98
in chronic cutaneous lupus
erythematosus 113
in dissecting cellulitis 128
in lichen planopilaris 106
in loose anagen hair syndrome 88
in non-scarring alopecia in systemic
lupus erythematosus 85
in postoperative alopecia 56
in senescent alopecia 36
in syphilitic alopecia 80
in telogen effluvium 45
in temporal triangular alopecia 59
in tinea capitis 136
in traction alopecia 53
in trichotillomania 50
club hair 6
club zone of catagen hair 7
collagen in aplasia cutis congenita 138
colloid bodies 103, 111
confetti-like pattern of hair loss 101
congenital triangular alopecia 5961
cornification in telogen hair 5
corticosteroids, use in central centrifugal

crumbling degeneration in inner root sheath
87
curlers, traction alopecia and 51
cytokeratin 153
decreased hair density 27
density, see hair density
dermis in aplasia cutis congenita 137
desquamation
of inner root sheath 94, 95
premature 32
discoid lupus erythematosus 26, 31, 109
114
dissecting cellulitis of the scalp 125129
cf. tinea capitis 135
early disease 126
polytrichia in 132
well-established 127
drugs and hair loss 43
dyskeratosis 111
dysmorphia after forcible plucking 10, 11
dyspigmentia 110
edema in alopecia areata 66
end-stage alopecia 116
end-stage traction alopecia 51
eosinophils in alopecia areata 66, 67
epidermal basement membrane zone in
chronic cutaneous
epidermis
interfollicular involvement in lichen
planopilaris 104
involvement in chronic cutaneous lupus
erythematosus 113
erythema
erythematosus 109
perifollicular 102
ethnicity in central centrifugal scarring
alopecia 91
exclamation mark hair 64
eyebrows, hair loss from 107
fat necrosis in postoperative alopecia 56
fibrous root sheath 2

finasteride 39
follicle
anatomy in catagen phase 4
anatomy of in trichotillomania 47
average number 21
destruction in lichen planopilaris 104
destruction in traction alopecia 54
distorted anatomy in transverse section
21
incomplete anatomy in samples 87
layers of 2
loss in aplasia cutis congenita 137
number and size in androgenetic
alopecia 39
premature desquamation of 94
follicular basement membrane zone in
chronic cutaneous
follicular degeneration syndrome 31, 91
follicular occlusion triad 125
follicular scars 117
follicular units 22
folliculitis decalvans 91
folliculitis keloidalis 119123
polytrichia in, 132
follicullitis, tufted 131
footprints in the snow 115
fractures in loose anagen hair syndrome 89
fragile hair 8
fragile nodes 142
frontal fibrosing alopecia 107
fungi
Microsporum canis 133
Pityrosporum in central centrifugal
tinea capitis 133136
Trichophyton tonsurans 133
Graham-Little syndrome 101
grooved hair shaft 89, 90
hair bulb 2
hair casts 151
hair colour in loose anagen hair syndrome
88
hair cycle, phases of 1

hair density
at lower dermis level 28
decreased 27
normal 27
normal but with clinical reduction of
hair amount 28
hair loss patterns of 33
Brocqs alopecia cf. other forms of
alopecia 115
in syphilis 79
hair miniaturization 29
hair relaxers
central centrifugal scarring alopecia
and 91
trichorrhexis nodosa and 141
hair shaft
abnormal shape in loose anagen hair
syndrome 88
disorders of 141151
grooved 90
hair sizes, terminal cf. vellus 1
hair specimens
acquisition 15
handling of 15
processing of 15
template for hair biopsy report 23
handling of hair specimens 15
heat, bubble hair 145
heavy metals 43
hemorrhage in trichotillomania 49
Henles layer 2, 90
hHb6 gene mutations 146
hidradenitis suppuritiva 125
histology
critical features and disease 2732
in acne keloidalis 122, 123
in alopecia areata 64, 75
in aplasia cutis congenita of the scalp
137, 139
in Brocqs alopecia 116, 118
in burnt-out scarring alopecia 118
INDEX 271

94, 98
erythematosus 111, 114
in dissecting cellulitis 125, 128
in lichen planopilaris 101, 106
in loose anagen hair syndrome 87, 88
lupus erythematosus 83, 85
in postoperative alopecia 55, 56
in pseudopelade 116
in senescent alopecia 36
in tinea capitis 133, 136
of androgenetic alopecia 37
of polytrichia 131
of senile alopecia 35
of telogen effluvium 44
of traction alopecia 52, 53
of trichotillomania 47
Huxleys layer 2, 90
hypergranulosis 103, 111
hyperkeratosis 111
hyperpigmentation 114
hyperthyroidism and telogen effluvium 43
hypopigmentation 114
hypothyroidism and telogen effluvium 44
ichthyosis linearis circumflexa 144
immunofluorescence
erythematosus 113
in lichen planopilaris 104, 105
immunoglobulin G granular deposits 111
inflammation 30
in burnt-out scarring alopecia 117
erythematosus 110, 111
in dissecting cellulitis 126, 127

lymphoplasmacytic 112
of lower half of follicle 30
of upper half of follicle
with vacuolar interface alteration 31
without vacuolar interface alteration
31
perifollicular lymphocytic 96, 120
inflammatory scarring alopecia, see central
centrifugal
scarring alopecia
infundibulum 2
acneiform dilatation of 128
of terminal anagen hair 4, 5
polytrichia and 97
inner root sheath
crumbling degeneration in 87
desquamatiom into outer root sheath 4
premature desquamation of 32, 93
isthmus 2
of terminal anagen hair 3
keratosis pilaris 101
lamellar fibroplasia 95, 96
in nuchal acne keloidalis 120
lichen planopilaris 101106
cf. central centrifugal scarring alopecia
102
early stage 102, 103
easy hair removal in 8, 10
end stage 105
late stage 104, 105
vacuolar interface alteration and
inflammation in 31
loose anagen hair syndrome 10, 8790
hair density and 29
lupus erythematosus, see discoid and
systemic
lymphoplasmacytic inflammation 112
matrix 2
Menkes kinky hair disease 147
metabolic disturbance and telogen
effluvium 43
Microsporum canis 133
miniaturization
in androgenetic alopecia 38, 41
in chronic alopecia areata 71
miniaturization of hair 29
minoxidil 39
monilethrix 146
mononuclear cell infiltrate,
morphea 26
mucin
dermal levels in chronic cutaneous
lupus erythematosus 111, 113
dermal levels in non-scarring alopecia
in systemic lupus erythematosus 84, 86
nanogen hair 71, 72, 73, 74
anagen-like 73
catagen-like 73
necrobiosis lipoidica 26
necrosis
of fat in postoperative alopecia 56
Nethertons syndrome 144
nodules in dissecting cellulitis 126
non-scarring alopecia in systemic lupus
erythematosus 8386
nuchal acne keloidalis 120
nutritional deficiency and telogen
effluvium 43
onion skin-like fibroplasia 95
papilla 2
papules

92
patterns of hair loss 33
Brocqs alopecia cf. other forms of
alopecia 115
in syphilis 79
pencil point hairs 6, 149
in alopecia areata 64, 65
peribulbar inflammation in alopecia areata
68, 69
perifollicular infiltrate in tinea capitis 135
perifollicular lymphocytic inflammation
120
perifolliculitis capitis abscedens et
suffodiens 125129
inflammation in 31
peripilar casts 151
pigment casts
as sign of trichotillomania 49, 50
pili annulati 144, 145
pili multigemini 147
pili torti 147
pili trianguli et canaliculi 148
Pityrosporum in central centrifugal
plucking
artefacts after 8
bulb after 10
pigment casts as sign of 49, 50
see also trichotillomania
polygonal hair shaft 89, 90
polytrichia 92
after healing 101
97
tufted folliculitis 131
pomades and central centrifugal scarring
alopecia 91
postoperative alopecia 5557
histology of 55, 56
pigment casts in 56
tissue necrosis in 56
INDEX 273
premature desquamation 32
of inner root sheath 93
pressure-induced alopecia in trichomalacia
32
processing of hair specimens 15
pseudofolliculitis barbae 119
pseudonits 151
pseudopelade 31, 91
pubic hair, loss of 101
pull/pluck findings,
anagen hair 10
catagen hair 10
dysmorphic 1013
snapped-off shafts 13
telogen hair 11
punch biopsy 15
pustules
92
radiation therapy, pencil point hairs 6
Rapp-Hodgkin ectodermal dysplasia 147
retinoids 43
telogen effluvium and 45
ringed hair 144
root
fibrous sheath 2
inner sheath 3
outer sheath 3
premature desquamation of inner
sheath 32
sampling, see hair specimens
sarcoidosis 25, 26
scalp
aplasia cutis congenita of 137139
appearance in alopecia areata 63
dissecting cellulitis of 125129, 125
129
normal adult 1
normal African American 22
normal Caucasian 22
normal in transverse section 20
sclerosis, in aplasia cutis congenita 138
sebaceous gland
follicular dropout with loss of 32

follicular dropout without loss of 32
presence in dissecting cellulitis 127
secondary hair germ 9
senescent alopecia 3536
crown in 35
histological findings in 35
occiput in 35
typical findings in 36
senescent balding 35
shaft, disorders of 141151
size, terminal hair cf. vellus hair 1
spongiosis, in alopecia areata 66
spun glass hair 148
squamous cell carcinoma, in dissecting
cellulitis 125
staphylococci in central centrifugal
stela 5, 8
in alopecia totalis 77
in androgenetic alopecia 38, 40
erythematosus 112
in nanogen hairs 73
in traction alopecia 52, 54
old cf. new 40
streamer, see stela
suprabulbar zone 2
in nanogen hairs 72, 76
of terminal anagen hair 3
syphilis
inflammation in 31
telogen effluvium in 79
syphilitic alopecia 7983
cf. alopecia areata 80
clinical findings in 80
diffuse 81
early 80
histology of 81
symptomatic 81
well-established 82
systemic lupus erythematosus,
inflammation in 30
non-scarring alopecia in 8386
systemic lupus erythematosus, telogen
effluvium in 44
tapered hairs 149
telogen count
determination of 21, 22
in dissecting cellulitis 127
in loose anagen hair syndrome 87, 88
in subacute alopecia areata 70
increase in androgenetic alopecia 39
telogen effluvium 33, 34, 4346
causes of 43
hair density and 28
in neonates 43
in systemic lupus erythematosus 44
syphilitic 79
telogen germ unit 5
telogen hair 1
anatomy of 5
early 9
forcibly plucked 10, 12
increased proportion 29
numbers in trichotillomania 48
percentage of as diagnostic feature 21
pulling of 6
terminal cf. vellus 9
temporal triangular alopecia 5961
hair density and 29
miniaturization in 59
terminal hair
anagen phase 2
cf. vellus hair 1
cf. vellus hair in traction alopecia 53
cf. vellus in telogen phase 9
ratio to vellus hair 23
ratio to vellus hair in telogen effluvium

45
tinea capitis 93, 133136
polytrichia in 132
traction alopecia 5154
braiding and 51
end-stage 51
gland 32
trichomalacia in 32
transient amplifying cells 6
transverse sectioning 1923
abnormal follicles 21
normal scalp 20
rationale of 19
technique for 15
trichogram 10
findings from 11
telogen count 12
trichomalacia 32
in postoperative alopecia 55, 56
Trichophyton tonsurans 133
trichorrhexis invaginata 144, 145
trichorrhexis nodosa 141
trichoschisis 142
trichothiodystrophy 142144
trichotillomania 4750
clinical findings 50
follicle anatomy in 47
hair density and 28
hemorrhage in 49
histological findings 50
pigment casts as sign of 49, 50
trichomalacia in 32, 49
tuberculosis, cutaneous 26
tufted folliculitis 131
tufting, see polytrichia
uncombable hair syndrome 148
vacuolar basilar degeneration 85
INDEX 275
vacuolar interface alteration and

inflammation 31
vacuolar interface change, in chronic
cutaneous lupus
erythematosus 110
vellus hair
cf. terminal hair 1
ratio to terminal hair 23
vertex, involved in alopecia 40
vitreous layer 2
changes in catagen hair 4
xeroderma pigmentosum mutations 142

Atlas of Hair Pathology PDF

Uploaded by

Document Information

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Atlas of Hair Pathology PDF

Uploaded by

Copyright:

Available Formats

An Atlas of HAIR PATHOLOGY WITH

THE ENCYCLOPEDIA OF VISUAL MEDICINE SERIES

The Parthenon Publishing Group

Published in the USA by

ISBN 0-203-59641-2 (Adobe eReader Format)

Normal hair anatomy and architecture

Specimen acquisition, handling and processing

Evaluating and describing transverse (horizontal) sections

Classification of hair disease

Distinctive or critical histological features and associated diseases

Senescent balding (senile alopecia)

Postoperative (pressure-induced) alopecia

Temporal triangular alopecia

Non-scarring alopecia from systemic lupus erythematosus

Loose anagen hair syndrome

Central, centrifugal scarring alopecia

Frontal fibrosing alopecia

Chronic cutaneous lupus erythematosus (discoid lupus

Brocqs alopecia (pseudopelade of Brocq) and burnt out

Acne keloidalis (folliculitis keloidalis)

Dissecting cellulitis of the scalp (perifolliculitis capitis abscedens

Aplasia cutis congenita of the scalp

Overview of hair shaft disorders

This textbook is the first comprehensive presentation of the microscopic

My interest in the pathology of hair disease was stimulated by Dr John

2 AN ATLAS OF HAIR PATHOLOGY

Anagen hair anatomy

NORMAL HAIR ANATOMY AND ARCHITECTURE 3

4 AN ATLAS OF HAIR PATHOLOGY

NORMAL HAIR ANATOMY AND ARCHITECTURE 5

6 AN ATLAS OF HAIR PATHOLOGY

Telogen hair anatomy

NORMAL HAIR ANATOMY AND ARCHITECTURE 7

PULLED, PLUCKED AND SPONTANEOUSLY SHED

8 AN ATLAS OF HAIR PATHOLOGY

process of plucking normal anagen hairs often leads to considerable artifactual

NORMAL HAIR ANATOMY AND ARCHITECTURE 9

10 AN ATLAS OF HAIR PATHOLOGY

Telogen pull/pluck findings

NORMAL HAIR ANATOMY AND ARCHITECTURE 11

12 AN ATLAS OF HAIR PATHOLOGY

NORMAL HAIR ANATOMY AND ARCHITECTURE 13

14 AN ATLAS OF HAIR PATHOLOGY

NORMAL HAIR ANATOMY AND ARCHITECTURE 15

16 AN ATLAS OF HAIR PATHOLOGY

NORMAL HAIR ANATOMY AND ARCHITECTURE 17

18 AN ATLAS OF HAIR PATHOLOGY

NORMAL HAIR ANATOMY AND ARCHITECTURE 19

20 AN ATLAS OF HAIR PATHOLOGY

NORMAL HAIR ANATOMY AND ARCHITECTURE 21

22 AN ATLAS OF HAIR PATHOLOGY

NORMAL HAIR ANATOMY AND ARCHITECTURE 23

24 AN ATLAS OF HAIR PATHOLOGY

NORMAL HAIR ANATOMY AND ARCHITECTURE 25

26 AN ATLAS OF HAIR PATHOLOGY

NORMAL HAIR ANATOMY AND ARCHITECTURE 27

28 AN ATLAS OF HAIR PATHOLOGY

NORMAL HAIR ANATOMY AND ARCHITECTURE 29

30 AN ATLAS OF HAIR PATHOLOGY

NORMAL HAIR ANATOMY AND ARCHITECTURE 31

SPECIMEN ACQUISITION, HANDLING AND PROCESSING 33

34 AN ATLAS OF HAIR PATHOLOGY

SPECIMEN ACQUISITION, HANDLING AND PROCESSING 35